Radiology Coding Alert
Know When to Overrule Impression With Indication Dx
Question: I’m working on a chest X-ray with an indicating diagnosis of chest pain and cardiomegaly documented in the impression. Should I code this as cardiomegaly? Montana Subscriber Answer: If there are no other indicating diagnoses referenced outside of the chest pain to refer to, you should not report code I51.7 (Cardiomegaly) as your primary or secondary diagnosis. That’s because you would be making a questionable assumption that the cardiomegaly is, in fact, related to the chest pain. Many patients with cardiomegaly are asymptomatic, and without any other underlying cardiovascular conditions to consider, you’d be taking an unjustified presumptive leap to definitively link these two conditions. Instead, you will report R07.9 (Chest pain, unspecified) as your sole diagnosis.
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