Radiology Coding Alert

Don't despair if an X-ray patient's medical record offers only "cough, rule out pneumonia" as a potential diagnosis. Simply take note of these three coding essentials, and you can be sure you're one step closer to choosing the best ICD-9 code for your report.

1. Base ICD-9 on Confirmed Dx When Possible When the radiologist documents a confirmed diagnosis based on the results of the test, you should report that diagnosis, says radiology coding consultant Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, of Schad Medical Management in New Jersey in her audioseminar "Radiology Documentation and Ordering Rules" (www.audioeducator.com).

For support, Schad cites Medicare Claims Processing Manual (MCPM), Chapter 23, Section 10.1.1, which applies to outpatient/office services (www.cms.hhs.gov/Manuals/IOM/list.asp).

Example: A patient presents for an abdominal CT with a "diagnosis" of abdominal pain. The CT reveals an intra-abdominal abscess, so the radiologist should report a diagnosis of "intra-abdominal abscess," the MCPM states.

For instance, if the radiologist documents an abdominal cavity abscess, you should report 567.22 (Peritoneal abscess).

You also may report the signs or symptoms that prompted the test as additional diagnoses if the confirmed diagnosis doesn't fully explain them, Schad says, again citing section 10.1.1.

Example: A patient presents for a chest X-ray because of a persistent cough, and the radiologist diagnoses a 3 cm peripheral pulmonary nodule. "The radiologist should report a diagnosis of 'pulmonary nodule' and may sequence 'cough' as an additional diagnosis," the MCPM states.

So you would report a code such as 518.89 (Other disease of lung, not elsewhere classified) for the nodule and 786.2 (Cough) for the symptom that prompted that chest X-ray.

Tests don't always result in a confirmed diagnosis. In that case, or when test results are normal, section 10.1.1 instructs you to report the signs or symptoms that prompted the study, Schad says.

Example: A patient presents for a spine X-ray because of "back pain." The results are normal, so the radiologist should report an ICD-9 code for back pain, which was the reason for the study, the MCPM states. For instance, if the order noted lower back pain, you should report 724.2 (Lumbago).

Signs and symptoms also will guide your code choice if the treating physician records a diagnosis preceded by words that indicate uncertainty and the results are normal, states section 10.1.1. This advice matches the rule for outpatient and office coding in the ICD-9 official guidelines, Schad notes:

"Do not code diagnoses documented as 'probable,''suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit" (www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm).

Example: A patient presents for a chest X-ray, and the order states "rule out pneumonia." The results are normal. "The radiologist should report the sign(s) or symptom(s) that prompted the test (e.g., cough)," the MCPM states. So you should report cough code 786.2 rather than a pneumonia code.

For you to report signs or symptoms, they must be written on the order, Schad says. If they aren't, contact the treating physician for a new order.

Coming next month: Thorough documentation helps eliminate the guessing game of choosing the proper radiology code, says Rita Huelar, CPC, a billing specialist who codes radiology services for Nemours Health System in Jacksonville, Fla. So what do you do when the ordering physician forgets to document symptoms and the test results are normal? Or what if the radiologist's documentation is so thorough he includes incidental findings? Discover where to look for ICD-9 codes in these case, plus get a sneak peek at ICD-10.