Radiology Coding Alert

Question: When the radiologist can't confirm a wrist fracture in a patient with wrist pain, which diagnosis should I report?

New Jersey Subscriber

Answer: When you don't have a confirmed diagnosis, ICD-9 guidelines instruct you to report the signs or symptoms that necessitated the test, such as 719.43 (Pain in joint; forearm) for the pain.

Support: Section IV.E states that "codes that describe symptoms and signs, as opposed to diagnoses, are  acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider."

And Section IV.I states that you should "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."

Online resource: You can find the official guidelines online at www.cdc.gov/nchs/icd/icd9cm.htm.