Wiki Radiology coding

[M1CcKb81]

For a diagnostic radiology report: If a patient came in with abdominal pain and was found to have diverticulitis, hiatal hernia, and renal & ureteral stones, would you code all of these diagnoses and which would be the primary diagnosis? Would it be considered inappropriate to only utilize one of the diagnoses? Asking after a discussion with another coder and was hoping someone could clarify this question.

 

[xXxPARAGONxXx]

https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines-updated-02/01/2024.pdf

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
K. Patients receiving diagnostic services only

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.

Therefore, you code all the aforementioned diagnoses, diverticulitis, hiatal hernia, and renal & ureteral stones, as they can each be a cause of the abdominal pain. Do not code the abdominal pain, which is a symptom code, since there are more definitive diagnoses. As for which one to code as the primary, it does not seem important which you choose as the primary diagnosis (unless the radiologist specifies a particular one to code as the primary) as each can be a cause of abdominal pain, and each, being a cause of abdominal pain, would support the medical necessity of the CT of the abdomen (I’m assuming that is what was performed).