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Kode has technically hired many but I've heard they have no charts yet & it's been quite a while so I would not panic.
The ICD-10-CM Official Guidelines for Outpatient Coding and Reporting contains guidelines specific to patients receiving diagnostic services only:
“For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89. Encounter for other specified ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 110 of 117 special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses”.
If the referring physician provides a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), the uncertain diagnosis should not be coded.
Furthermore, if the results of the diagnostic test are normal or a definitive diagnosis has not been made by the radiologist, signs/symptoms prompting the ordering of the test should be identified and reported.
Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses. It is recommended to report any incidental findings that may warrant additional follow-up studies
5 Steps for Selecting the Primary Dx Code
Exercise caution in using information documented only in the summary of findings and not documented in the impression. Often the radiologist will comment on everything that he sees visualized on the images, but not all findings noted are clinically significant for the exam being performed.
- Review the information documented under the “impression” for any definitively diagnosed conditions.
- Review the clinical indications to determine if those conditions listed in the impression are related to the exam, or unrelated incidental findings for the exam ordered. The clinical indications on the report should match those on the order from the referring physician.
- Review the summary of findings in the body of the report if necessary to clarify the diagnostic information provided in the impression. Sometimes this may be helpful in adding specificity for coding a particular condition.
- Choose the primary diagnosis code based on the guidelines in the section above title “Choosing the Primary Diagnosis” after considering and determining all pertinent findings in the radiology report.
- Assign diagnosis codes for any other additional pertinent findings. Incidental findings may be coded after all clinically significant findings are reported. Incidental findings are abnormal findings not specifically related to why the exam was performed but discovered during the exam.
Diagnosis Radiology Coding Guidelines
Ensuring diagnosis coding is complete and done in accordance with the official radiology coding guidelines is more important than ever. Click to learn why.www.dexioscorp.com
Ancillary Services
In the medical world, ancillary services are supportive or diagnostic measures a physician may use to help treat patients. During a hospital stay, for instance, anything that does not include room and board or direct care by a physician or nurse is ancillary. Laboratory tests, X-rays, ultrasounds or services such as physical therapy all fall under this umbrella. An ancillary coder first identifies the patient's diagnosis and then matches the treatments or diagnostic studies ordered by his physician with the appropriate code. A typical workday for an ancillary coder requires extensive knowledge of medical terminology and excellent analytical skills. Although she has little direct patient contact, if any, an ancillary coder must possess the ability to communicate effectively with physicians and other health care professionals.
It’s All in the Details
To ensure optimal insurance coverage, ancillary coders spend much of their day matching the severity of a patient’s diagnosis with the appropriate treatment codes. A patient may, for instance, have elevated blood pressure during an office visit but no formal diagnosis of hypertension. In this case, laboratory studies may differ in code from those the patient would receive if he has been hypertensive for years. Or, if a patient is having problems with severe asthma, his physician will likely order more intensive diagnostic studies than she would for someone with only mild asthma. If the ancillary coder matches a high-level evaluation code with a mild asthma code, the patient's insurance company will at least review and may even deny coverage for the evaluation.
What Does an Ancillary Coder Do?
Every illness and medical procedure has a unique and nationally recognized set of letters and numbers, or code that identifies it for the insurance company you hope will cover most of the bill. Coding begins with a physician diagnosing a patient's illness in the medical record. A medical coder...
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“If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.” - let’s say the radiologist list in findings thus study is for non diagnostic for pulmonary embolism…. Would this be example to use x code and dx code ?
Yes, all findings should be documented in the record to be coded as it is the coder's motto, "if it's not documented it wasn't done."
Although as to where these are found in your documentation may be in different places as many EHRs are slightly different.
A few common examples of findings that might be considered incidental are:
The following examples illustrate incidental findings:
- MRI Brain: Atrophy or ischemic changes in the elderly
- CT Abdomen: Fatty liver or liver cyst
- CT Pelvis: Diverticulosis
It should never be assumed that any particular condition is always incidental. What is considered incidental for one patient and one study, may not be considered incidental for another patient and another study. When there is difficulty in determining whether or not a finding is incidental or whether or not it should be reported, it is prudent to query the radiologist.
- A patient is referred for an abdominal ultrasound due to jaundice. After review of the ultrasound, the radiologist discovers the patient has an aortic aneurysm. The primary diagnosis is jaundice and the aortic aneurysm may be reported as a secondary diagnosis.
- A patient is referred for a chest x-ray because of wheezing. The x-ray is normal except for scoliosis and degenerative joint disease of the thoracic spine. The primary diagnosis is wheezing since it was the reason for the patient’s visit. The other findings may be reported as additional diagnoses.
- A patient is referred for an MRI of the lumbar spine with a diagnosis of L-4 radiculopathy. The MRI reveals degenerative joint disease at L1 and L2. The primary diagnosis is radiculopathy and the degenerative joint disease of the spine may be reported as an additional diagnosis.
Diagnosis Radiology Coding Guidelines
Ensuring diagnosis coding is complete and done in accordance with the official radiology coding guidelines is more important than ever. Click to learn why.
It is inappropriate to report an incidental finding found on a radiology report when the finding is unrelated to the sign, symptom, or condition that necessitated the performance of the test for a patient being seen.
Incidental findings should never be listed as primary diagnoses. If reported, incidental findings may be reported as secondary diagnoses by the physician interpreting the diagnostic test.
A typical example would involve a patient whose visit was entirely unrelated to the queried condition. Following the visit, the physician would be queried to add a suspected diagnosis, such as atherosclerosis of the aorta (hardening of the walls of the aorta), based on a historical radiology report from years prior. The medical record would contain no indication that the physician was aware of this historical report at the patient visit, let alone that the physician considered or addressed the condition at the patient visit. Often, the addendum would just include the diagnosis or would copy portions of the query into the medical record. The medical record would likewise contain no indication that the physician even contacted the patient about the brand-new diagnosis.
The chart review program violated the ICD Guidelines because it involved the systematic creation of addenda for conditions that were entirely unrelated to the visit. Because the explicit purpose of the program was to identify “new” diagnoses that had never been made by a physician, a physician queried to add a chart-review diagnosis could not have been previously aware of the condition, and certainly could not have considered, evaluated, or treated the condition at the visit. The ICD Guidelines therefore prohibited the coding of such conditions, yet Kaiser submitted thousands of such diagnoses for tens of millions of dollars in risk adjustment payments.
When To Report an Incidental Finding
DOJ lawsuits may be your road map to risk adjustment compliance. The growing prevalence of risk adjustment in healthcare has forged new processes in DOJ lawsuits may be your road map to risk adjustment compliance.www.aapc.com
Services Reported Separately
Any specifically identifiable procedure or service (ie, identified with a specific CPT code)
performed on the date of E/M services may be reported separately.
The ordering and actual performance and/or interpretation of diagnostic tests/studies during a
patient encounter are not included in determining the levels of E/M services when the
professional interpretation of those tests/studies is reported separately by the physician or other
qualified health care professional reporting the E/M service. Tests that do not require separate
interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an
independent interpretation, but may be counted as ordered or reviewed for selecting an MDM
level. The performance of diagnostic tests/studies for which specific CPT codes are available
may be reported separately, in addition to the appropriate E/M code. The interpretation of the
results of diagnostic tests/studies (ie, professional component) with preparation of a separate
distinctly identifiable signed written report may also be reported separately, using the appropriate
CPT code and, if required, with modifier 26 appended.
The physician or other qualified health care professional may need to indicate that on the day a
procedure or service identified by a CPT code was performed, the patient’s condition required a
significant separately identifiable E/M service. The E/M service may be caused or prompted by
the symptoms or condition for which the procedure and/or service was provided. This
circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As
such, different diagnoses are not required for reporting of the procedure and the E/M services on
the same date.
T
. I'm currently doing some practice in AHIMA virtual medical coder cases (rad clinic). Ran across something doing a Rad note. So in this note of course the doc strictly listed findings and conclusions. I managed to pull all my DXs. I took out cardiomegaly ( I51.7) due to the excludes 1 note, " I51.7 should not be coded the same time as I70.90. Since I70.90 was my primary dx, I proceeded to take out the I51 code. Once again, with the info given it was straightfoward and no indication in the note that those two conditions were "unrelated". However, the AHIMA answer key kept the I51 code. In addition to this I also noticed the answer key included another dx I took out due to an Excludes 1 note I encountered (again I didn't see any indication in the RAD note the 2 conditions were unrelated). 