Wiki Radiology Diagnosis Coding

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hshcoder

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Is it appropriate to use the result of a Cat Scan exam to support ordering the test? I am being asked to code from the test results when applying diagnosis codes for the encounter when the test was ordered. I feel that since they don't know the result at that point, it would be inappropriate to use that information. Thoughts?
 
Yes a physician coder or outpatient facility coder may code from the radiology interpretation report, inpatient facility coders may not.
 
Sbbcpc

If I'm understanding your question correctly, the provider who ordered the cat scan must provide a reason for ordering the cat scan. You can not code strictly from the report alone. The first listed code would be the reason for the cat scan being ordered on the requisition from the ordering provider. The second listed code would be the primary result or finding from the cat scan report. You may code other findings from the cat scan report as additional codes. You may also code chronic or related diagnosis from the requisition. Hope this helps.
 
You would not code the reason for ordering these along with the definitive diagnosis. You can code the reason for the test if you do not wait for the result , or you code the definitive diagnosis from the interpretation. The exception is screening. F the reason for the test is screening, ou always use the screening code first, if the is an abnormality found during the screening it will be a secondary diagnosis.
 
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