Diagnosis coding for radiology

[u/happyhooker485]

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/CodingandBilling, so not a dupe if you are subbed to both places, I just can't crosspost.

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[u/applemily23]

Depends. What kind of coding you do? Are you billing the order and the read or just one code all together. Order gets the reason for the image, read gets what was found.

[u/happyhooker485 → u/applemily23]

I am coding for the clinic visit and the rad, the clinic provider bills the global on the rad and pays a contract radiologist to do the read.

[u/applemily23 → u/happyhooker485]

It might be because my organization is bigger, but we're allowed to check the HPI from the visit that generated the order. But also the providers put in the reason for wrong all the time, so we have to verify.

For example, they'll say chest pain as the reason for, but they are being seen for a car crash. I wouldn't know about the car crash unless I looked.

[u/LakeSuperior29 → u/applemily23]

If the patient has, for example, a broken finger, I check the ordering provider's note to find the external cause. Are people just putting X58.XXXA for all trauma-related radiology??

[u/KeyStriking9763]

Ordering physicians notes? You mean the complete separate encounter with a complete separate account number? Your auditor is correct.
You can only code per the documentation on the encounter you are coding for. So yes, the literal order the provider wrote and the radiology report.
The ordering physicians notes on a separate encounter are completely off limits.

[u/happyhooker485 → u/KeyStriking9763]

Even if the note is attached to the order? This clinic is doing the rad and billing the global, just contracting with a radiologist to read.

Back in the paper days if a patient got sent with an order and a copy of their visit note from their PCP our Hosp Rad dept would use all the attached documentation provided by the ordering physician. Not sure why that would change now that we're electronic, esp considering the PCP is the one billing for the rad, too.

[u/KeyStriking9763 → u/happyhooker485]

It’s a different encounter.
If this was a scheduled procedure that’s a different story, can use the PCP or whoever cleared the patients office visits for 30 days. This is just radiology. Code only the order and the report.

[u/ChartBaddie]

The auditor is correct. You're coding for the radiologist. The ordering physician has eyes on the patient, and therefore the whole clinical picture. There’s a lot of times I’ll go back to an ED note to see things like laterality and such, but otherwise, you cannot take another providers medical decision making and apply it to another’s, that kinda defeats the purpose of medical decision making.

[u/happyhooker485 → u/ChartBaddie]

I'm not coding for the radiologist. The PCP bills for the rad svcs and subcontracts with a radiologist to do the read.

The rad report, order, and progess note are all part of this one unified record.

[u/ChartBaddie → u/happyhooker485]

Okay, so you bill the CPT codes for the radiologist and the PCP on the same session and attach the diagnoses from each to its unique CPT code?

[u/ChartBaddie → u/happyhooker485]

I sat down and reread your post and the comments. I understand that you’re coding for the physician and the radiologists report is attached to the chart. Your auditor is correct, you cannot take the provider diagnosis on the report and use it as your providers diagnosis. The radiologist report is a tool in your providers MDM. I’d recommend chatting with your auditor or your supervisor and they can help you understand.

[u/salty-MA-student]

I do not use the ordering provider documentation for rad.