Wiki new to radiology diagnosis--Help please

[LuckyLily]

I am a new coder and I am now coding diagnostic radiology, however I am having a hard time with it.

I come across PICC placements. I would use V58.81. Would you code something else with this such an underlying reason why they are getting a PICC. The reports are just to see if they are placed properly and no additional information.

I also come across where a patient has had "trauma" or "fall" on a body site. An x-ray is performed but everything is okay. Do you code this an INJURY by site?

Also I'm confused with Aftercare codes.

I feel really frustrated. I did great in school and taking tests but actually coding these I am getting so confused and my employer is not giving training.

 

[Dhaneshmurali]

PICC line/Injury/Aftercare

Hi,

1) PICC line placement - If the patient came for (Reason for exam) PICC line/tube placement, you can use 58.81/v58.82 code for the primary dx.

- If you seen in the document PICC line as incidental finding, you can use as secondary dx, depends upon your provider instructions.

2)Injury/Fall - You can take code 959.9 for injury as a unspecified site (If No site specifications in your document). You shouldn't take site specific injury code unless your provider/client instructions states take site specific code.

3) Aftercare - Reason for the exam/visit is primarily for post care or aftercare for specific conditions (fracture, replacement,surgeries) then only we are using aftercare codes as primary dx and conditions as secondary dx.

- Dont use aftercare codes for the acute conditions, that means at the day of fracture, replacement, surgery conditions.


Dont worry about working in radiology coding. Initially it is littlebit confuse to memorising codes, guidelines, provider instructions. If you are crossing your experience 3 to 6 months in radiology, you will really feel how much it is easier compare to other specialities in coding.


Regards,

Dhanesh M

 

[mitchellde]

When a patient presents for evaluation following a fall or trauma and no injury is found then it is incorrect to assign 959.9 since that code state that an injury is present, instead use V71.4 or V71.6 first listed, which states observation following accident or injury with nothing found.
Yes use the V58.81 for the PICC line, and all aftercare will be the appropriate V code for aftercare. If you can state your specific or generic confusion with aftercare I can be of greater assistance but generally you do not use a code for a condition that does not exist, so post operative evaluations will be aftercare unless there is a stated complication.

 

[Dhaneshmurali]

Yes, ofcourse we can use v71.4/v71.6 for fall/assault if nothing stated about injury in impression or final diagnosis.