You Be the Coder:
Coding Patient History
Published on Sat Jan 01, 2000
I>Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: Weve been told we can code only the clinical history supplied by the ordering physician. Despite our best efforts, this is often lacking or bears no relation to the exam ordered. Can additional history obtained directly from the patient (by asking them why we are doing the exam or from questionnaires the patient completes) be used for coding and justification of an exam?
Anonymous Calif. Subscriber
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Answer: Radiology practices are not limited to information provided by the ordering physician, according to Garnet Dunston, CPC, MPC, coding consultant with Dunston Enterprises in Phoenix, Ariz., which specializes in Radiology Coding. She notes that radiologists and their clinical staff members may question patients about their clinical history in order to provide a more accurate diagnostic (ICD-9 code). Whether done verbally or through a questionnaire, the data should be recorded in the patient record and the attending physician should be contacted for a verbal order. The attending is required to sign the verbal order within 48 hours.
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