Wiki Can you code and bill diagnosis from radiology ordering script?

[she803]

Hi everyone. I work in radiology dept at a hospital as a coder. I work with another coder and a manger who is a coder as well. My manager tells the other coder if the diagnoses on radiology exam order of procedure being done is not as detailed as the ordering script from the referring physician. For instance, an ER physician requests on a script to have an X-ray exam done for left forearm with dx of left forearm fracture, however the Radiology physician who receives this script documents the exam order as "unspecified forearm fracture" not including "left" in the order as the diagnoses. The coding manager tells the coder since the exam order is diagnosed as "unspecified forearm fracture" to not use that dx because it will deny, but instead use the diagnoses from the order script that states "left forearm fracture." The coder disagrees and says that it's to be coded based on the exam order from radiology physician and NOT the script from the ER physician. Please assist. And thank you in advance for your time!

 

[mantlaua]

I personally would code specificity from the physician order in this instance rather than an unspecified diagnosis. There is a coding clinic 4Q 2016 that indicates "when available, coders may use radiology results to provide greater specificity". I would think the same would apply to this scenerio and I feel any documentation signed by an authorized provider whether the ordering provider or radiologist that supports more "site" specificity could be used.