Wiki Dx coding for xrays

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MarciaH

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All through college in my coding classes, we were told over and over that you DO NOT code for "suspected, rule out, possible" but now that I'm in a podiatry office I'm confused. What do you code for an xray due to a possible fracture, looking for a foreign body and so on but don't find a fracture or foreign body? My office manager (who isn't a CPC, has only learned through trial and error) says to code for fracture or foreign body. I'm not comfortable with this due to my training but don't know where to go for the correct info. Is she correct or is she miscoding? Please help!!!
Marcia, CPC-A
 
MarciaH said:
All through college in my coding classes, we were told over and over that you DO NOT code for "suspected, rule out, possible" but now that I'm in a podiatry office I'm confused. What do you code for an xray due to a possible fracture, looking for a foreign body and so on but don't find a fracture or foreign body? My office manager (who isn't a CPC, has only learned through trial and error) says to code for fracture or foreign body. I'm not comfortable with this due to my training but don't know where to go for the correct info. Is she correct or is she miscoding? Please help!!!
Marcia, CPC-A
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Hello,
You are correct in feeling uncomfortable... I am a radiology coder as well as Emergency medicine and If there are no findings on the xray exam, then outpatient coding guidelines state you must code the signs or symptoms that prompted the test, pain in limb, foot, etc. If only rule out/suspected is on the xray report, then send back to ordering md to clarify, in writing and attach to report. This is fine for documentation and auditing purposes as well as coding guidelines.

thanks tommie
 
hello

I m radiology coder for last 2 + years in coding company in india also cleared CPC . when this type of codition arries, we send back to physician to clerify the situation. if you found any injury or pain or other symptoms, you can give it. many physician specify that in that case you can code V71.89.
thanks and regards
dr sunil dadhich CPC-A
 
Tommie,
Thank you soooo very much!!! I have even lost sleep over this since I'm new and not sure about approaching "experienced" people but yet at the same time I do NOT want to put my credentials in jeopardy.

I know you can code pain for an xray but is there any other symptom that would justify an xray? Would swelling qualify?
Thanks again,
Marcia
 
drdadhichsunil said:
I m radiology coder for last 2 + years in coding company in india also cleared CPC . when this type of codition arries, we send back to physician to clerify the situation. if you found any injury or pain or other symptoms, you can give it. many physician specify that in that case you can code V71.89.
thanks and regards
dr sunil dadhich CPC-A
Click to expand...
Thank you! That helps me.
Marcia
 
Usually in the front of every ICD-9 book it will give you instructions on coding radiology which reiterates what everyone has said above. I thought you might want some documentation of proof for your manager. Hope it helps.
 
I have over five years radiology coding experience. I agree with Tommie. Swelling would probably work fine for an x-ray. Use signs and symptoms and as a last resort if you don't have anything else, V71.89 can be used for a suspected foreign body not found.
 
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