Radiology Coding Alert

Question: I have a diagnostic radiology report for an encounter where the patient presented with abdominal pain. After imaging tests, the radiologist documented their findings as diverticulitis, hiatal hernia, and renal and ureteral stones. Will I code all the diagnoses or only one of them?

Codify Subscriber

Answer: You will report all the diagnoses documented in the radiology report on your claim, since they can all be the cause of the abdominal pain. But you will not report the abdominal pain, which is a symptom code, because the radiologist issued more definitive diagnoses.

You’ll assign K57.92 (Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding) to report the diverticulitis diagnosis, unless the provider’s documentation specifies which intestine the condition is affecting. Next, you’ll assign K44.9 (Diaphragmatic hernia without obstruction or gangrene) for the hiatal hernia. Finally, assign N20.2 (Calculus of kidney with calculus of ureter) to report the renal and ureteral stones.

According to the ICD-10-CM Official Guidelines, section IV.K, “sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.”

Any of the codes mentioned above can be listed as the primary diagnosis as each condition can be the cause of the abdominal pain. Of course, if the radiologist specifies a particular condition as the primary diagnosis, then you’ll code that diagnosis first.