Wiki x ray documentation

[coderforlife]

I have a question. We have a emr template for ordering x rays. The way this document is setup is as follows: I will also input some of the data for my question.

date of study 3-9-10
study ordered 3 views left knee
indication v67.00

interepetation post op, stable no indication of fracture.

Okay the problem I have is with the icd9 code and his interepetation. I believe the code should indicate the reason for ordering the x ray. I do not believe a v67.00 is valid for this purpose. Also my doctor was very vague in his interepetation of these films which makes it very difficult to code this document. Any suggestions are welcome. Okay not really a question just looking for input regarding this situation.

coderforlife

 

[jbaird]

You may want to print out the ACR Practice Guideline for Communication of Diagnostic Imaging Findings and give that to your doctors to review. It is helpful in letting them know what needs to be on their dictation for ease of coding and compliance. Here's a link:
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/comm_diag_rad.aspx
Another good resource on ACR is clarification on the ordering of diagnostic tests rule:
http://www.acr.org/Hidden/Economics...rchives/MayJune2007/ICD9CodingGuidelines.aspx