Radiology findings can help support your physician queries

by Lynne Spryszak, RN, CCDS, CPC-A

Radiology reports, such as CT and MRI scans, x-rays, and ultrasounds, frequently contain detailed information that can lead to more specific code assignment. Coding Clinic advice supports the use of radiology findings to obtain additional information regarding the coding of the specific site of fractures.Specific information often found in CT or MRI scans can assist with diagnoses of cerebral edema or compression of the brain. These two diagnoses, when reported, add severity to a record because they are considered MCCs in the MS-DRG system. They also represent increased ROM in other classification systems.