How To Code A Diagnostic Radiology Report

Lindsay Della Vella

4 years ago

Sometimes when people hear that diagnostic radiology coders can code 50+ reports an hour they are taken back for a minute. It sounds like a lot, and it is, but there’s many factors to think about how someone can code that fast. For example, do they have an encoder? Are they coding both icd 10 and cpt? Modifiers? What software are they using? But there is a method to the madness and some coders can code very fast, even if just from coding from paper the old school way.

Here is the process I use for diagnostic radiology coding. There is no “right” or “wrong” way but maybe it will help you get faster too.

First–look at the header of the report–see if all the info is there.
Then look at the technique–does it match the header?
Then code the CPT.
Look to see if it needs a modifier (example 59, 76, 77 or an X modifier).
Skim report–including reason for exam and impression.
Code the ICD-10-CM codes from the impression if there are findings. If not code the reason for exam.

Basically it takes practice, but to quote an old teacher-“The more you practice the better you get.”

Looking for practice reports? Join our coding community. This is the membership only part of our website and there are practice diagnostic radiology reports posted weekly. It is also a forum where you can post your coding questions and I will be there for you as a mentor. It is geared towards people still taking their coding classes or certified coders who have an interest in learning about diagnostic radiology coding. Check it out here.