1. ANNEMARIE EDWARDS
   Posted 1 year ago #
   

   FREESTANDING IDTF IMAGING CENTER RECEIVES AND ORDER FOR AN XRAY OF THE ELBOW AND THE ORDERING DX IS "ELBOW FRACTURE AFTER INJURY". THE TEST IS NEGATIVE FOR FRACTURE. HOW WOULD THIS BE CODED? PLEASE USE REFERENCES FOR YOUR ANSWER(IE: ICD9 GUIDELINES OR PUBLISHED INFO FROM SOURCE SUCH AS CPT ASSISTANT). I'M SEEING MORE OFTEN THAT ORDERING MD'S ARE STATING THE "RULE-OUT" AS AN EXISTING CONDITION ON THE ORDER. WE TOLD THEM NOT TO USE RULE OUT AS AN ORDERING DX SO IT SEEMS THEY JUST DROPPED IT FROM THE CONDITION. WITHOUT CONTACTING THE ORDERING MD OFFICE FOR MORE INFO(BECAUSE THEY DON'T WANT TO BE) AND NO OTHER RECORDS TO SEARCH FOR SYMPTOMS, HOW WOULD YOU CODE THIS STATED JUST AS IT IS ON THE ORDER AND TEST RESULTS BEING NEGATIVE?

2. SuperCoder
   Posted 1 year ago #
   

   The Ordering Dx is something in this context, the Ordering MD wants to confirm whether the "fracture" is present or not. By documenting Ordering Dx as "Elbow Fracture after Injury", he is directing the Imaging center to focus the findings if there is a fracture of elbow or adjacent anatomical region, and also giving the information that if there is finding of a fracture, then this is result of an injury as per his assessment.

   But, if the test result comes out negative, then as per ICD guidelines, the "Reason for Visit", i.e., Injury as mentioned in Ordering MD's documentation, then injury of the anatomical site is to be coded for diagnosis purpose.

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