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CODING SYMPTON

Peter Posted Wed 17th of August, 2011 14:27:14 PM

PT COMES INTO OFFICE WITH MIGRAINES AND NECK PAIN. NO OTHER COMPLAINTS. BY PHYSICIAN IS WANTING TO DO A TRANSCRANIAL DOPPLER. HER INSURANCE DOES NOT COVER DX CODE OF SYMPTOMS ABOVE. CAN I CODE "REASON FOR TEST" AS DIAGNOSIS?

SuperCoder Answered Wed 17th of August, 2011 19:40:24 PM

Sure. The Dx codes for a CPT, particularly in Radiological procedures based on descending sequence of priority are:
Primary underlying condition for which the test is performed;
or
Primary Pertinent Findings;
or
Primary Reason for Visit;
or
Primary Related Symptoms;

SuperCoder Answered Thu 03rd of November, 2011 15:55:23 PM

So, for radiological imaging, would I use, for instance, patient was seen by the physician due to neck pain; the physician orders an MRI of the CS to rule out Disc Herniation etc; if the MRI report shows that the patient does have a CS disc bulge, lets say, would I bill using 722.0 or #1 722.0, then #2 723.1 since neck pain was the reason the patient was seen in the first place. My instincts tell me only the Disc Bulge, correct?

SuperCoder Answered Fri 04th of November, 2011 02:55:06 AM

You are right. In such a case, we should code 722.0 only.
When you are coding a diagnosis for a radiology report, you need not to code the signs and symptoms of the term which is coded as diagnosis. So, when you are coding 722.0, you should not bill neck pain(723.1)along with 722.0

Peter Posted Tue 15th of November, 2011 16:09:15 PM

I was under the impression you could not code a "rule out"?? Am I wrong?

Melissa Answered Tue 15th of November, 2011 17:12:10 PM

Correct you do not code rule out, questionable, or suspect

Peter Posted Tue 15th of November, 2011 17:27:36 PM

Ok..then I am confused. The above comments stated code 722.0 which this is what the physician was "ruling out". How can you code disc herniation?
If my phyician has ordered a diagnostic test with the symptoms of dizziness but wants to rule out TIA...how is this coded? Symptoms, correct?

SuperCoder Answered Tue 15th of November, 2011 18:13:24 PM

Let me summarize the all of the above:
1. If the Radiological exam(MRI)is performed to rule out disc bulge, and the MRI report above as you said "MRI report shows that the patient does have a CS disc bulge", then you should code 722.0
But, if findings didn't confirm disc bulge, then you should code 723.1
*
2. In the same way, if for the symptoms of dizziness, diagnostic test ordered to rule out TIA. If the test shows the "findings of TIA", then you should code TIA. If "TIA" is not confirmed, then you should code dizziness only.

Peter Posted Thu 17th of November, 2011 14:34:21 PM

Thanks Sanjit!

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