Coding diagnoses for radiology professional component reports
We would like to ask a question regarding coding diagnoses for radiology professional component reports. Should we code additional findings documented in the body of the report or code only the impression or final definitive diagnosis?
The diagnosis code(s) you report should relate to the reason for the exam. That may be a definitive diagnosis in the impression/findings, but it may need to be the symptoms that the ordering physician (hopefully) gave you. Additional, incidental, findings may be added as secondary, but should never be primary. You don’t have to add them, but you can. Medicare used to have a section in the claims processing manual that said incidental findings could be added. Coding Clinic has more recently said that incidental findings would not be coded.
The official guidelines for diagnosis coding, in Section IV, G say:
“G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the [provider].”
If you have a symptom, but the radiologist gives a definitive diagnosis related to that symptom, then you code only the definitive diagnosis.
What you cannot do is report symptoms or diagnoses that are uncertain: ruled/out, consistent with, compatible with, differential diagnoses, possible, likely, etc.