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Question: Coding from the hx section of a radiology report: I was under the impression these diagnosis codes are coming from the patient or technician and not from the ordering provider. I am seeing a lot of facilities coding these diagnosis codes to meet medical necessity and justifying them because the radiologist signed off on the report. I am correct that this is wrong that you cannot code from the hx section?
Answer: Our guidance has been to only code confirmed conditions (in the final impression of the rad report).
Here is the latest Coding Clinic for using x-ray reports.
Using the X-ray Report for Specificity
Coding Clinic, First Quarter 2013 Page: 28
Question: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, in ICD-9-CM if the record describes a fracture of the leg and the radiology report identifies a specific site of the leg, we are allowed to code that more specific site. Will this be true also in ICD-10-CM as well? For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Previous advice stated that we can code the fracture. Is this still valid for I-10?
Can you also address if the following advice will apply in ICD-10: An outpatient encounter for pain with no site mentioned and an x-ray is done and we are instructed to code pain of that site of the x-ray. Will the same advice be true in I-10?
Answer: The same advice would apply to more specific coding in ICD-10-CM. If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.
Additionally, in the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the finding are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.
In the outpatient setting, if the diagnostic tests have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
- Tasha Cameron, RHIA, CCS, CDIP
Question: Can I still put diagnosis for perineal laceration 1st degree, but the provider did not repair or not treated?
Answer: Generally, this diagnosis still meets reporting requirements. Many 1st degree lacerations close spontaneously and often do not require suturing. Thus, the fact that the laceration was not repaired is not uncommon. If the physician took the time to document it, there is usually something mentioned in the nursing notes, the care plan, etc. that addresses the diagnosis. According to the UHDDS, "For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring."
There was probably a wash, a solution, a cream, soothing (witch hazel) pads, cool compresses, or likely directions for sitz baths or at least ibuprofen or other pain medication recommended or administered.
- Dwan Thomas Flowers, MBA, RHIA, CCS
Question: What is the guideline for documentation of intraoperative cholangiography during laparoscopic cholecystectomy 47563? Is it enough to see the surgeons noting in the operative report that the cholangiography was done or should we look for more affirmative documentations to support the procedure?
Answer: Surgeon noting in the operative report that cholangiography was done is not enough documentation. In intraoperative cholangiography, the common bile duct is directly injected with radiopaque material. The surgeon removes the gallbladder. Stones appear as radiolucent shadows. Gallstones, tumors, or strictures cause partial or total obstruction of the flow of dye into the duodenum. There should be sufficient documentation within the body of the operative report to support 47563.
- Bella Logvinov MBA, CCS, CPC