GSCoder07
Networker
I am new to radiology coding and I need some clarification.
Here is the scenario:
A patient, who is an inpatient, is experiencing shortness of breath. The physician orders a chest x-ray. The radiologist reports in the impression that opacities and pleural effusions are seen. Do we code the opacities and pleural effusions or do we code the shortness of breath? I have been coding straight from the impression. Is this correct? Are the rules different for inpatient and outpatient?
Also, I have been coding EKG's as well and have only been coding from the findings. Are there rules for EKG's as well?
Are there clear coding guidelines somewhere for radiology & EKG's? If so, can someone please direct me where to find them?
Thank you in advance for your help!
Here is the scenario:
A patient, who is an inpatient, is experiencing shortness of breath. The physician orders a chest x-ray. The radiologist reports in the impression that opacities and pleural effusions are seen. Do we code the opacities and pleural effusions or do we code the shortness of breath? I have been coding straight from the impression. Is this correct? Are the rules different for inpatient and outpatient?
Also, I have been coding EKG's as well and have only been coding from the findings. Are there rules for EKG's as well?
Are there clear coding guidelines somewhere for radiology & EKG's? If so, can someone please direct me where to find them?
Thank you in advance for your help!