Radiology Coding Alert

Question: We performed a retroperitoneal ultrasound. The admitting diagnosis header says, "AAA." The clinical history header says, "Possible AAA." The impression says, "Negative ultrasound examination of the abdominal aorta, with no evidence to suggest an abdominal aortic aneurysm." The ordering physician gave AAA as the diagnosis for the exam. Can I use the ordering physician's diagnosis of AAA even when the exam is negative?

Indiana Subscriber
 
Answer: Evidently the referring physician hadn't confirmed that the patient had an aneurysm, because it didn't show up on the ultrasound. And if the aneurysm wasn't confirmed, the physician should have given the radiology department the patient's signs or symptoms or other reason why the physician thought the patient might have an aneurysm.

Unfortunately, you don't have that information, so you will need to go to the referring physician for clarification.

The official ICD-9 guidelines instruct you not to code a diagnosis documented with terms indicating uncertainty for office and outpatient services (www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf).

Even for short-term, acute care, long-term care and psychiatric hospitals, you can only code an uncertain diagnosis as if it exists if the diagnosis is still uncertain at discharge, per the guidelines.

Tip: You can help prevent problems like this by having the technologist or registration staff ask the patient about his symptoms at the time of the examination. Just be sure that you have the information documented, such as on a patient questionnaire form.