Home » Categories » ICD-9-CM Coding

Coding Signs and Symptoms vs. Imaging Results


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?


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
Hypertension and Diabetic Chronic Kidney Disease
Viewed 3278 times since Thu, May 12, 2011
Trunk Piercing
Viewed 736 times since Wed, Jan 30, 2013
Family History vs Screening Colonscopy
Viewed 1204 times since Tue, May 8, 2012
Recurrent Subdural Hematoma
Viewed 4717 times since Wed, Oct 12, 2011
Pleural Effusion & Atelectasis Coding
Viewed 3320 times since Mon, Jun 13, 2011
Coding Supplemental Oxygen
Viewed 2931 times since Wed, Apr 6, 2011
Viewed 110 times since Thu, Jan 20, 2011
POA for intraoperative bleeding
Viewed 1057 times since Tue, Jun 14, 2011
Procedure Code-Delivery Following Fetal Demise
Viewed 4161 times since Sat, Jan 29, 2011
Sepsis secondary to line infection and pneumonia
Viewed 4932 times since Tue, Dec 27, 2011
Quorum Health Resources, LLC :: 105 Continental Place Brentwood, TN 37027 :: Phone: (615) 371-4506