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Radiology Coding Alert

You Be the Coder:

Remember to Exclude Secondary Dx Codes in the Impression

Published on Mon Sep 11, 2017

Question: I am working on a chart with an impression documenting spondylosis causing spinal stenosis at L2-L3. Additionally, there is spondylolisthesis at L3-L4. The impression states radiculopathy. Should I include all four of these diagnoses? California Subscriber Answer: Generally, you won't be documenting symptoms when there are definitive findings in the impression. However, this rule only applies when the diagnoses in the [...]
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