Home » Categories » ICD-9-CM Coding

Coding Signs and Symptoms vs. Imaging Results


Question

The out patient’s order lists signs and symptoms for the chest x-ray. The report comes back negative. Do we code from the report or can we use signs and symptoms?

Answer

Coding rules allow you to do either.  The official guideline is: 

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 V72.5 and a code from subcategory V72.6. 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 V 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.

Disclaimer: All articles intended for general guidance only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.

Attachments Attachments
There are no attachments for this article.
Related Articles RSS Feed
Influenza A
Viewed 4172 times since Fri, Feb 18, 2011
Age range on Radiology Examination
Viewed 16372 times since Wed, Jun 15, 2011
Acute vs. Chronic Rotator Cuff Tear
Viewed 11886 times since Thu, Apr 14, 2011
Debridements
Viewed 1399 times since Wed, May 11, 2011
Incidental Findings
Viewed 3327 times since Fri, Apr 22, 2011
Fracture
Viewed 1194 times since Sat, Nov 26, 2011
Pancreatic lesion
Viewed 5789 times since Fri, Jun 24, 2011
Spine Coding
Viewed 50 times since Wed, Oct 12, 2011
Pediatric vs Adult BMI
Viewed 2594 times since Wed, May 4, 2011
Viabahn Endograft
Viewed 3356 times since Mon, Apr 11, 2011
Quorum Health Resources, LLC :: 105 Continental Place Brentwood, TN 37027 :: Phone: (615) 371-4506