For this week’s post, I thought I’d talk about just some general things relating to diagnostic radiology coding. Bear in mind, this isn’t the be-all-end-all, everything-you-need-to-know guide. This is just what I would tell a new coder who had limited experience with this specialty in a nutshell.
- First things first–radiologists can be vague in their documentation. They like to use words like “consistent with,” “probable,” “rule-out” etc. In the outpatient setting–you do not code uncertain diagnoses. So if you come across a report with these terms, do not code it. A common phrase I see in the impression on chest x-rays is “consistent with pneumonia.” Since it is not definitive, you would not code the pneumonia–you would code whatever the symptoms are. There is a coding clinic however that states that the use of the words “Evidence of” is not a vague term–so you can code the condition.
- When you’re coding, refer to the impression. If there is a finding, it will be listed here, and this is where you code from. If there are no findings, you would code the history/symptoms stated on the report.
- When you’re coding x-rays, you count up the number of views to get the CPT. Sometimes the radiologists may mention images–do not count images. It is not the same thing as views. (If you want to learn more about x-ray coding, don’t miss the boat on our online class).
- Another thing to keep in mind is to always follow all client specific guidelines. For example, do you code an addendum? Do you need to add a modifier 26? All of these types of questions will be answered in your client guidelines. (A good rule of thumb is to review your client guidelines before reaching out to the lead coder for questions).
- Know the difference between limited and complete ultrasounds (refer to the CPT book).
- Know the difference between all the different OB ultrasounds (refer to the CPT book).
- CTA’s must state 3D in the documentation.
- Know whether or not you need to code the contrast for MRI and CT scans. Do you code contrast waste? Again, review client guidelines on these types of questions.
- Know whether or not you need to code incidentals. The answer to this is generally no, but this is another client guideline type question.
- Last but not least, know how to code fractures. If this is new to you, see this previous blog post.
So there you have it. Hopefully this list helped you figure out a little more about diagnostic radiology coding.
Thanks for reading-
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