Diagnostic Radiology Coding Basics

10 Things You Need To Know Before Coding Diagnostic Radiology

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.

  1. 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.
  2.  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.
  3. 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).
  4. 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).
  5. Know the difference between limited and complete ultrasounds (refer to the CPT book).
  6. Know the difference between all the different OB ultrasounds (refer to the CPT book).
  7.  CTA’s must state 3D in the documentation.
  8. 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.
  9. Know whether or not you need to code incidentals. The answer to this is generally no, but this is another client guideline type question.
  10. 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-

 

 

 

 

 

 

 

Midnight Medical Coding Products You Might Be Interested In:

 

Learn The 50 Most Common X-Ray CPT Codes-

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15 Question Practice Coding Test

Practice coding the ICD-10-CM and CPT codes of HIPAA compliant X-ray reports. Answers and rationales provided.

 

 

 

 

 

Join the Midnight Medical Coding Stars- A membership only area where one HIPAA compliant diagnostic radiology report is added each week for you to code the ICD-10-CM and CPT codes. Answers provided.

 

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Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.

 

 

 

 

 

 

 

 

 

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ICD-10-CM Book Tabs

How To Tab The ICD-10-CM Book

For a long time, I didn’t tab any of my coding books. Well, wait that might not be entirely true. I used to have 1 tab for the Neoplasm Table and that’s it. Not sure why I never put the time in to tab the books the right way. But the long and short of it is, I already thought I was a great coder–why did I need to tab my books?

 

 

But then as I was getting things together and planning the x-ray cpt coding class, I was thinking about all the ways that would make coding easier for my students and I did a 180. I started thinking about the tabs again and how beneficial it would be. So, I made a set of tabs to put on my book to show as an example. Later on, when I was working, I realized how much faster I was coding. It was like night and day.

 

 

Every coder I know, whether they’re a newbie or not, worries about not coding fast enough. If you work as a production coder, you need to think about whether or not  you are meeting your company’s production requirements. Speaking of which, if you’re not, there are things you can do to improve productivity–see this freebie. So, anyway, back to the books. I’ve put together a quick video showing you how to tab the ICD-10-CM book. See below:

 

If you want to tab your books, but there’s too much on you plate– you can purchase a set of these tabs:) The ones you see in this video are a sample. What you see is what you get. These tabs have gotten great reviews–please see the sidebar on the right of your computer.

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Product is shipped in 1-3 business days.


Make a long story short, these tabs really do work and make life easier. If you’re still on the fence about it, go here to see more pics. Please feel free to reach out to me at midnightmedicalcoding@gmail.com if you have any questions.

 

 

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Uncategorized

Coding Tip- Always Follow Client Guidelines

Ok, well this might be a no-brainer, but always follow client guidelines. I know you already have to think about all of the ‘real’ coding guidelines, but that does not mean that clients don’t have their own that you must follow too. This makes your job as a coder a little more difficult because there’s more to remember, but eventually you’ll be able to code and your clients guidelines will become second-nature.

So, what am I talking about exactly? Most clients that I’ve coded for have their own set of rules. I’m not saying that these contradict real coding guidelines, but basically clients have rules too. For example, there may be guidelines on whether or not to use the LT/RT modifiers or modifier 50. There may be client guidelines on what to do if the report has documentation issues, or if some info is completely missing. You should know if your client wants outside reads coded because some do, some don’t. A very important one you should know is whether or not your client needs you to add modifier 26 or not. You will get this info before you start actually working for the client. They should send you a pdf or another document specifying their guidelines.

There could be many different client guidelines and the ones I mentioned are just a few that are possible. Always remember to check your client coding guidelines if you come across a situation that you’re unfamiliar with and you will hopefully find the answers to your questions. If not, then the best thing to do would be to contact your lead coder/coding manager for clarification.

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