Wiki Must we code from report at outpt diag fac

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srouleau

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When coding an outpatient diagnostic procedure (ex: MRI, CT), do you HAVE to code a diagnosis from the report? Case in point, the doc read an MRI and there is no report available when I am coding said MRI. Can I code from signs/symptoms or do I need to wait for the report? Thanks!
 
If you're coding the professional component (physician's interpretation and report) then you must wait for the report.

If you're coding onlyfor the technical component, you code based on the reason for the test, such as would be documented by the order.

If you're coding globally, then you must wait for the report as well.
 
Must we code from report from outpatient diagnostic facility

I would only code whatever the doctor wrote in the impression (sign or symptoms/definitive diagnosis) as long as it is not a rule out or probable diagnosis. If the doctor did not write the reason for the diagnostic procedure, I would query him/her as to the medical necessity of the diagnostic procedure.
 
You do not have to wait.

(emphasis mine)
According to Official Guidelines, Section IV, L
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

According to CMS, Claims Processing Manual, Chapter 23, Section 10.1.2
D. If the individual responsible for reporting the codes for the testing facility or the
physician's office does not have the report of the physician interpretation at the time of
billing, the individual responsible for reporting the codes for the testing facility or the
physician's office should code what they know at the time of billing. Sometimes reports of
the physician's interpretation of diagnostic tests may not be available until several days
later, which could result in delay of billing. Therefore, in such instances, the individual
responsible for reporting the codes for the testing facility or the physician's office should
code based on the information/reports available to them, or what they know, at the time of
billing.
 
Although I understant CMS's guidelines, if you don't wait until your final report, you may receive a subsequent denial based on an ambiguous diagnosis. Also...if the order states a suspected condition (such as lung cancer), and the final report rules out the cancer, then you've coded incorrectly and given the patient a diagnosis they don't actually have. This happened to me personally, as a matter of fact.

I stand by my recommendations, as a best-practice approach. Our diagnostic results are interfaced into our EMR within 24-48 hours, so delayed billing is rarely a problem, except for the unusual pathology.
 
srouleau said:
When coding an outpatient diagnostic procedure (ex: MRI, CT), do you HAVE to code a diagnosis from the report? Case in point, the doc read an MRI and there is no report available when I am coding said MRI. Can I code from signs/symptoms or do I need to wait for the report? Thanks!
Click to expand...

Outpatient coding guidelines state that if the report is available at the time of coding, you can code from the final report - but not that you must wait for it. So, no - you don't have to wait for the final report.

However, the most accurate information about the patient's condition is derived from the report, so it is preferrable to wait until you've got it; especially in cases where the signs and symptoms may not show medical necessity for the services, as well as the definitive diagnosis would. (For example, if a patient is being given an x-ray for joint pain, when the doctor suspects rheumatoid arthritis - a confirmed Dx of RA would be far more likely to be payable, than 'joint pain' would).

Hope that helps! ;)
 
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