Radiology Coding Alert

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 the reason for the radiology exam, but only if the radiology report does not have any findings listed. If the radiologist listed findings in their report, then you’ll use the findings to assign the correct code.

Let’s examine two examples to further illustrate this situation.

Scenario 1: A patient presents to the radiology facility with complaints of severe right lower leg pain. The patient’s primary care provider (PCP) ordered X-rays to check for a fracture. The radiologist captured anteroposterior (AP) and lateral X-ray views of the tibia and fibula. After reviewing the images, the radiologist compiled their report with unremarkable findings.

Scenario 2: A patient presents to the radiology facility with complaints of severe right lower leg pain. The patient’s PCP ordered X-rays to check for a fracture. After capturing and reviewing AP and lateral X-ray views of the tibia and fibula, the radiologist documented a closed fracture of the right tibia.

In the first scenario, you’ll assign M79.661 (Pain in right lower leg) as the reason for the visit since the radiologist didn’t list a condition in the findings. In this scenario, you’re correct to consult the PCP’s order to code the reason for the visit.

In the second scenario, you’ll assign S82.291A (Other fracture of shaft of right tibia, initial encounter for closed fracture) to report the closed right tibia fracture.