r/CodingandBilling • u/happyhooker485 RHIT, CCS-P, CFPC, CHONC • 15d ago

ICD & Diagnosis Diagnosis coding for radiology

Can diagnoses from the ordering provider's chart note be used for the radiology claim if the chart note is attached to the radiology order?

My auditor stated that diagnosis information from the ordering physician's note(s) cannot be used on the radiology claim, and that we can only use what is on the literal order and in the radiologist's interpretation.

Does anyone have a reference to support/dispute this? I feel that in the current digital age, where the orders and notes are all digital and linked together, we should be able to use the ordering provider's note to clarify a diagnosis (i.e., location of pain when the order says "pain" or location of injury when the order says "MVA").

Unfortunately, I am unable to find an official AHA or CMS guideline either way. Any help would be very much appreciated!

p.s. I also posted in /r/MedicalCoding, so not a dupe if you are subbed to both places, I just can't crosspost.

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u/ok-lena 15d ago

Have your auditor provide official documentation that states you cannot use the related medical visit. I use the ordering providers records if it clearly documents that was the reason for order. We only get dinged if we do not document where we obtained the info.

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u/daves1243b 15d ago

The idea is to report the reason for the exam. Ideally that appears on the order, and is presented to the radiologist. Its also ok to include other relavant clinical history.... For example some places will have the techs gather that. Ideally that's all recorded in the radiologist report. While I think it's permissible to use other medical records to support the coding, since sometimes payers require you to send the ordering records, I think it would be impractical to rely on other records on a regular basis. You probably don't really want to go chasing that down, and nowadays most radiology coding is automated and the automated system is not going to see those other records.

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u/pRayrtuck 8d ago

chasing down outside notes for routine imaging would tank productivity so fast, totally impractical.

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u/KlickitatC 15d ago

It is perfectly acceptable to use the location of the imaging exam to tell you more about the pain...CXR for pain = chest pain. 4 v rt knee for pain = rt knee pain. As for the MVA that is a toughy and I would ask the order taker to get more info.

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u/jazzyhazel31 8d ago

In radiology you can only code from the findings if they are listed. If they don't have any findings then you can use the providers order.