Wiki Coding from radiology order

[LuckyLily]

Is it okay to code the diagnosis from a diagnostic radiology order when the report is not available yet. For instance, patient comes in for screening mammogram but report takes several weeks to come through (don't know why). Is it okay to code it with the screening mammogram code that is on order.

What about other diagnostic radiology encounters. For example ultrasound, x-ray etc...and the report is not available?

 

[Pam Warren]

In the facility setting, this is often how it's done. In outpatient coding, the reason for the visit is the diagnosis that is reported, and that's provided on the order. If you are coding for the radiologist's read, then you must wait for the interpretation/report.