Wiki Coding of Kidney stones.

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dha_coder

dha_coder

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Need radiology coding help.....

The Pelvic X ray report given as follows,

Indication : Kidney stones

Body of the Report: No stones found in the kidney or ureter.

Impression : No renal calculi found.

Our educator suggest to use 592.0, because of medical necessity.

I think this is not a right way of coding the report.

Please suggest.

Thanks in advance.

Dhanasekaran S
CPC, CCS, CPC-P
Quality Analyst in Medical Coding.
 
Hi Dhana,

As per my view V13.01 is correct.

I think you know the false claim policy of HIPPA

Thanks


Vijaykumar M. CPC
 
sha07vk said:
Hi Dhana,

As per my view V13.01 is correct.

I think you know the false claim policy of HIPPA

Thanks


Vijaykumar M. CPC
Click to expand...

How do you know the patient has a history of renal calculi? You wouldn't know that any stones were there prior to the x-ray. You can't use this V code unless the record says they have a history. If they have then it is appropriate. If not I would go with the signs and symptoms that necessitated the radiological exam such as renal colic or abdominal/flank pain.
Just my opinion.
 
Hi,

This is a hospital outpatient setting and more over nothing mentioned in physician order exept kidney stone.

Thanks & best regards,

Dhanasekaran S
CPC, CCS, CPC-P
Quality Analyst in Medical Coding.
 
Last edited:
I would code the Kidney stone since that was the indication from the physician who put the order in for the exam.
 
Or better yet go back to the Doc and see if there is something else that can be ammended to the report such as abdominal pain ot history of. I agree you cant give them a V history code if it is not stated as a history of..
 
Coding of Kidney stones

Nothing mentioned in the PO except kedney stone, No any sign or symptom.

This is the follow up visit for the previous renal calculi for rule out purpose.

My question is can we pick the code from PO(Kidney stone) if the present document says normal.:confused:

Regards,

Dhanasekaran srinivasan
CPC, CCS, CPC-P.
 
I think u can give v72.5 Radiological examination, not elsewhere classified, as no signs/symptoms or history documented.
 
Coding of Kidney stones

Can we use V72.5 for followup exam or the provider try to rule out a problem, I think V72.5 is not correct code. Any one can throw light on this issue.....

Regards,

Vijayakumar M CPC
 
I would agree with Always Sunny, especially if this is a follow up. If you can't get anything more from the doctor as far as symptoms, I would use 592.0 for the kidney stone.
 
You would not use the code for a kidney stone since clearly there is none, you should not code from the physician order rather you need the office note that generated the order to get the full picture, if the suspicion is kidney stones but then it is not so use a V71.- code for evaluation for suspected condition not found, or use the symptoms from the office note.
 
I see this occasionally in the radiology practice where I work and I send these reports back to the physician for documentation of the signs and symptoms. Believe me, after they amend a few reports for this they will start including the symptoms on a regular basis when no kidney stones are found.

Best of luck to you:)

Tracey Morehart, CPC
 
I do agree with Tracey ... :)

As per ICD guidlines, If Dx is supected/Not exists/Probable we need to code underlying symptoms for the cause. And if not mentioned then send these reports back to the physician for documentation of the signs and symptoms.
 
you cannot assign any follow up codes here, see the description of follow up

V67 Follow up examination
Includes: Surveillance only following completed treatment

Here the patient is not coming after the treatment and he/she just to come for the evaluation, hence V72.5 is the only code which we can use and there is no signs or symptoms noted in the record.

Hopes that help!

Thara L CPC H
 
You can not code renal/kidney stones if the documentation does not support it. In addiditon the documentation must also support a history a calculli to use the V codes. The physician needs to be queried for more documentation or you must code underlying symptons only.
 
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