Wiki Hospital diagnosis coding

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donnagullikson

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Radiology report comes over with presenting diagnosis of intercoastal pain R07.82 and also multiple fractures of the right ribs. The report is a PA and Lateral chest and the reports says nothing about rib fractures. The way I'm teaching our coders is if the report doesn't state there's fractures we cannot use that presenting diagnosis unless its documented in the finding. I would code this R07.82. Is this correct and is there any documentation that states not to use the presenting diagnosis from the hospital so I can give this out to our coders?

Thanks and have a great day.
 
You wouldn't be able to determine R07.82 on a radiology report just like the fractures were not there so why leave out the fx codes. It is on the order that the doctor has documented. I would use both.
 
When you say the presenting diagnosis is "intercoastal pain R07.82 and also multiple fractures of the right ribs", is that direct verbiage from the order? Is there an "indication" or something equivalent listed on the order? Basically, what was the reason(s) they were requesting the images? I can probably help clarify the inpatient/outpatient DX coding if you can give a bit more information.
 
Diagnosis coding

We never see the orders as we're a billing office. All we get is what the hospital sends us and the presenting diagnosis from the hospital states "intercoastal pain". They were looking for multiple rib fractures due to the intercoastal pain.

Thanks,
 
If it stated the diagnosis was pain and they were looking for fractures, then there was never a diagnosis of fractures. Therefore when the radiology report does not confirm fractures, then you are left with the presentation of pain as the only diagnosis. You cannot code what the patient does not have.
You also stated this was hospital coding, inpatient facility coders are not to code from radiology reports, only physician or outpatient coders may do this.
 
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