Guest Post: Use radiology findings to support your physician queries

by Lynne Spryszak, RN, CCDS, CPC

A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is not “code-able”—that is, it is not information that may be used for diagnosis code assignment. Coders may only use documentation contained in select portions of the record—that which is provided by “hands-on” providers (i.e., those providers legally accountable for establishing a diagnosis).

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. See the following references for more information:

• Coding Clinic, First Quarter, 1999, p. 5 (fracture site specified in radiology report)
• Coding Clinic, Second Quarter, 2002, p. 3, (ED coding using the radiological findings)

Note, however, that this guidance does not pertain to assigning diagnosis codes for conditions that the treating provider does not specifically identify or document.

Editor’s Note: This article first appeared on JustCoding.com. ACDIS members can read the entire article when it is published in October edition of CDI Journal. At the time of this article's original release, Spryszak was an independent HIM consultant based in Roselle, IL. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development.