Wiki xray Dx codes

[keoughnurse@yahoo.com]

I am new to my job and am coding radiology. I see a lot of "Degenerative changes with joint space narrowing" and "narrowing of the disk space" for impressions. Any insight on how to code those? It doesn't state OA so I don't want to do that because I am not sure if it's ok to do that.
Thanks
Christina

 

[thomas7331]

ICD-10 and CMS guidelines both instruct that, for outpatient services, if a definitive diagnosis has not been confirmed by the provider at the encounter, the symptom for which the patient is being evaluated should be reported. In your examples above, I believe the provider is documenting their observations or findings in the images but stopping short of giving a definitive diagnosis. In these cases, the most appropriate coding would be to use the indication that was given for the test rather than trying to translate these impressions into ICD-10 codes that don't really fit.

 

[sarab86]

On all my radiology coding/billing I only bill the indication for the study, NOT what is thought to be found or the outcome of that scan. Example, if a lumbar xray is performed because the patient presented with back pain and they are ruling out a fracture I bill with DX Lumbago-M54.5.

Carriers stopped accepting rule out DX any years ago and you cant know going in what going to be found. That is diagnosed on the follow up exam.