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Radiology Coding Alert

Reader Questions:

Refer to the Medical Record When No Findings Are Present

Published on Wed Jan 24, 2024

Question: I am coding for a radiology encounter from an independent diagnostic testing facility (IDTF). The radiologist didn’t document any specific conditions in the report’s findings. Can I use the reason for the radiology exam listed in the referring provider’s medical record to code to a higher level of specificity? Codify Subscriber Answer: Yes, you may use the referring provider’s note as [...]
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