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
Orthopedic Aftercare (V54 series)
Viewed 3216 times since Fri, May 6, 2011
Hypotension
Viewed 1281 times since Thu, Jul 7, 2011
Outpatient Surgery To OBS
Viewed 878 times since Thu, Oct 6, 2011
Remission vs History
Viewed 5710 times since Tue, Oct 4, 2011
Screening Mammogram w/ other Tests and DX
Viewed 1367 times since Wed, Dec 21, 2011
Pancytopena
Viewed 1834 times since Mon, Sep 19, 2011
Age range on Radiology Examination
Viewed 12098 times since Wed, Jun 15, 2011
Pleural Effusion & Atelectasis Coding
Viewed 2550 times since Mon, Jun 13, 2011
Principal Diagnosis Assignment on ED Patient
Viewed 1389 times since Mon, Oct 10, 2011
Viabahn Endograft
Viewed 2578 times since Mon, Apr 11, 2011
Quorum Health Resources, LLC :: 105 Continental Place Brentwood, TN 37027 :: Phone: (615) 371-4506