Radiology Coding Alert
Choose This Dx Code for Unremarkable Findings
Question: A patient presented to our radiology practice with complaints of sharp right upper leg pain. The radiologist captured anteroposterior (AP), lateral, and posteroanterior (PA) X-ray views. The radiologist noted in the report that there were no fractures. What diagnosis code should I report? Nevada Subscriber Answer: You’ll assign M79.651 (Pain in right thigh) to report this encounter. The patient presented with upper right leg pain, but the radiologist didn’t find any fractures in the X-rays. In that case, you’ll use the symptoms the patient was experiencing as your ICD-10-CM codes. According to the ICD-10-CM Official Guidelines, section I.B.4, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.” This means that if the provider doesn’t make a specific diagnosis regarding the patient’s condition then you will use codes describing the patient’s symptoms.
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Choose This Dx Code for Unremarkable Findings
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