Wiki xray diagnosis

[solocoder]

So, if the reason documented for the xray exam is "foot pain" and the results in the xray report say bunion and hammertoe, how do I know if this is the cause of the "foot pain"? Maybe the patient ends up with a diagnosis from their physician of plantar fasciitis? How do I know whether to code the bunion and hammertoe, or the foot pain with bunion and hammertoe next as incidental findings?

 

[Pam Warren]

A radiologist that reads the Xray is a physician....not sure I get your question.

Are you coding for the facility? Then the reason for the xray (admitting diag) is foot pain, but the final diag would be the bunion and hammertoe. That's what you'd report for the facility charge for the xray.

If you're coding for the physician, you wouldn't use the radiologist's diagnosis for the physician's charge. You'd use the physician's documentation; unless he validated the radiologist's report and noted its clinical significance.

Good luck.

 

[solocoder]

These podiatrists read their own xrays, not a radiologist. So I code the visit with the podiatrist AND the xray . I get them both together in the clinic note.
Still not clear on which code to use for the xray.

 

[sarab86]

I work for neurosurgeons and they read their own MRI and xrays as well at the visit. For the radiology portion I code the symptoms with those CPT codes. For the E&M done I code the result with the 992--. Does that help? I always look for the pain with the xrays/MRI and the condition being treated for the E&M.