RADIOLOGY DIAGNOSIS CODING CONCEPTS

Do not code for conditions, if stated as following:-

• Most likely...
• Symptom "typical of" condition
• Likely...
• NOT consistent with...
• Felt to be consistent with..
• Most consistent with...
• Symptom "Suggestive of "condition
• Concerned that the patient has...
• Presumed...
• Appears to be...
• I suspected this is...
• Suspicious of...
• I think this is...
• May have...
• Suggests...
• Indicative of...
• Thought to be present...
• Almost certainly...
• Seems to be...
• Probable...
• May represent...
• Reflects...
• Consistent with
• Compatible with
• Do not code incidental findings or unrelated co-existing conditions

Never code for conditions or diagnosis documented as“probable, suspected, questionable, rule out or working diagnosis or other similar terms indicating uncertainty of an condition (such as consistent with or compatible with).
- Instead code the condition to the highest degree of certainty or reason for that encounter such as symptoms, signs, abnormal test results or other reason for visit.

Coding Chest x- ray

RFE = Pain, Imp=normal --- code pain
RFE =Pain, Imp – COPD --- code COPD
RFE= Pneumonia, Imp = infiltrate--- code Pneumonia
RFE= Pneumonia, pain, Imp= normal--- code pain
RFE= Infiltrate, Imp = infiltrate– code Infiltrate
RFE = Chest pain, Imp – infiltrate – code Infiltrate
RFE- Pneumonia, Imp-Normal- Pneumonia
RFE –Pneumonia, Imp- cosolidation- Pneumonia
RFE- Pain, Imp- atelectasis/ effusion- Chest pain
RFE = Chest pain, Imp – consolidation – code consolidation
RFE = COPD, Imp – Emphysema – code emphysema alone

Coding Skeletal X-rays

• RFE = pain, swelling, imp= normal --- code pain
• RFE= pain, imp= OA/Degeneration --- code OA
• RFE=pain, imp= Fracture, OA, code: Fracture
• RFE = Fracture, dislocation ---- code fracture

Coding- OB secondary DX’s.

Some OB codes need sec dx , so while coding OB dx look for notes given below / above the code in ICD manual, If guidelines is given to code additional code,code the appropriate sec dx. (sec dx is given to further specify the complication)

When the patient reason for visit is to check pregnancy & its not confirmed in US examination. Code it as OB US with non OB dx followed by V72.40/Z32.00.

When the patient reason for visit is unrelated to pregnancy & the US examination proves pregnancy. Code it as Non OB US with V22.2/Z32.00. as the secondary diagnosis to indicate the pregnancy is incidental finding.

Coding -DEXA / Bone densitometry

Axial skeleton- 77080
Appendicular skeleton- 77081

• When the report states both Appendicular and Axial measurements were done, only one is coded –axial measurement is coded(77080) Generally ,axial and
appendicular measurements are not performed together.

• In certain cases both 77080 and 77081 are done, and if there is different medical necessity then it can be coded as 77081, 77080 – 59.

General Instructions:-

For screening tests (those performed in the absence of signs/symptoms) assign the appropriate V/Z code(findings are coded as secondary).

While assigning ICD codes, code the diagnostic condition relevant to the procedure performed. The primary diagnosis generally should justify the reason for the encounter.

Use complication diagnosis codes series, when something went wrong because of the
procedure done. (tube clogged), Dislocation of THR  etc.

If the diagnosis is not definite (ex. atelectasis and/or infiltrate), code for other specified diseases of that particular organ.

Congenital anomaly codes should be used, only based on the patient's age. E.g.: For a patient of 90 yrs, do not use congenital diagnosis when it is not mentioned so.

Do not code for a condition which has completely resolved, recovered, healed, or which is no longer existing.

Incidental findings should not be coded as a primary diagnosis per ICD-9-CM coding guidelines even if it is a payable diagnosis.

But incidental findings can be coded only secondary as long as it is payable.

When to code from the impression only: Only when the clinical indication or the reason for the exam is a sign and/or symptom of the diagnosis from the impression. The symptom wouldn’t be coded as an additional diagnosis when the primary diagnosis is payable.

When to code signs and symptoms in addition to the diagnosis from the impression: Only when the diagnosis from the impression is not payable. The correct sequencing would be code the diagnosis from the impression first and then the signs and symptoms
as secondary diagnosis.

Code from the body of the report in addition to the diagnosis of the impression, when the Diagnosis from the impression is not payable.

Code the diagnosis from the report if that is the only available diagnosis even if it is non payable.

A condition from the Rfe can be coded, only when there is no impression , no signs & symptoms is given in the report.

Always code INJURY as primary. Watch out for the words fall, MVA, MVC, twisted, trauma, s/p trauma, multi-trauma, trauma alert etc. 

When a patient comes in with trauma/injury/fall/MVA, never code for any
degenerative changes or other irrelevant findings.

Use 959.8 /T07.XXX in the case of multitrauma & if injury is in more than two sites.

Unless the document state particular site injury code it as 959.9/T14.90X –
unspecified injury.

There is no specific guideline that states on how long an injury needs to be considered as acute.
Hence, if a patient comes in for initial treatment of the injury, it can be considered as acute.

Do not code for injury in the following cases:

Remote injury/fall/MVA. In such cases code for the late effect of injury 
Late effect of MVA/FALL are also coded as sequela.

Note:-

Ligamentous Injury should be considered as Sprain.
Crushed toe, Jammed finger, these type of injuries are classified as crushing injuries.

Coding- Injury

Injury, Pain (any signs & symptoms) – Code pain(signs & symptoms), then injury

Trauma, pain - Code pain, then injury,

Contusion, injury- Code contusion
Laceration, injury – Code laceration (wound, open, by site)
Fall, pain – Code Pain
Fracture, injury, pain – Code only fracture
RFE = trauma, imp - dislocation  code= dislocation
RFE = Injury, haemorrhage = code haemorrhage
RFE= contusion/bleeding/injury, imp = normal  code=haemorrhage
When the patients RFE is fall / MVA / MVC without documentation of any symptoms or outcome of the fall or MVA then it has to be coded as V71.4/Z04.3
For Assault without documentation of any signs,symptoms or any out come of assault, has to be coded as V71.6/Z04.8
When there is documentation of any symptom or outcome of fall / MVA / MVC or assualt then the symptom should be coded and no need to code V71.4 / V71.6/Z04.3/Z04.8.

Criteria for high risk screening for Breast.

When the patient satisfy any one of the below criteria, code V76.11/Z12.31 as the pri dx followed by respective sec dx.

Personal history of breast cancer or BCT (Breast Conservation Therapy) – V10.3/Z85.3
Family history of breast cancer in mother, sister or daughter –V16.3/Z80.3
No child till the age of 30 – 
Nulliparous (Never given birth to a child) – 
Personal history of biopsy proven breast beningn diseae –

Metastasis:

Spinal charts:

Sequencing of Spinal Findings –
- Spinal cord abnormality
- Disc protrusion / extrusion / herniation / tear
- Spinal canal stenosis
- DDD / Narrowing of disc space
• - DJD / Facet degeneration / Spondylosis / Degenerative
changes of facet joint / Degeneration of L/L2, C1/C2
- Disc bulge / Discitis / Disc disorder / loss of disc height
- Spondylolisthesis / Anterolisthesis / Retrolisthesis
- Scoliosis

• When there is documentation for “loss of disc height”along with any disc pathology (disc protrusion, extrusion,herniation, tear or bulge) then alone use the code for degenerative disc disease.
• If there is documentation for “loss of disc height” with out mention for any disc pathology then this has to be coded as “Disorder of IV disc” and not as degenerative disc disease.
• Narrowing of disc space should be coded as DDD, as this is the way our ICD manual directs.