Below are the rules as listed by CMS. I will say I only use the report as my coding source. Not the order. We have hospital based radiologist and I often do not have access to the order.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf
Rules for reporting diagnosis codes on the claim are:
• Use the ICD-9-CM code that describes the patient's diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis.
• Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
• Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable.
• Code a chronic condition as often as applicable to the patient's treatment.
• Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.)
For outpatient claims, providers report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in the appropriate FL. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported (786.2). If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported (466.0).
The CMS requires following the ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based and physician office). These guides instruct physicians to report diagnoses based on test results, if available. The Coding Clinic for ICD-9-CM confirms this longstanding coding guideline.
A. Confirmed Diagnosis Based on Results of Test
If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis.
A. On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.