Radiology coding tips for radiology coders

Radiology coding involves coding of radilogy charts like CT's, MRI's, X-rays, Ultrasounds, nuclear medicine, mammograms. Here we attempt to detail all the scenarios that a radiology coders experiances while coding radiology charts. One basic rule in radiology coding is that if the radiology report are normal than indications should be coded as primary diagnosis. For example, if cough is the indication for chest x-ray and the x-ray report is normal, than cough should coded as primary diagnosis, and if x-ray findings is pneumonia than pneumonia is coded as final diagnosis.

Chest X-rays are taken after abnormal PPD skin test. Here abnormal PPD result ICD-9 code 795.5 should be used as admitting diagnosis and final diagnosis could be the x-ray findings or 795.5 in case of normal results.

Breast mammographic studies are done either for diagnostic purposes or for routine screening. For diagnostic mammographic studies code the indication (lump, density, calcifications) as admitting diagnosis and mammographic findings as final diagnosis. If mammographic findings are normal then indications are coded as final diagnosis.

For screening mammograms, screening codes should be sequenced first and mammographic findings can be coded as additional codes.

Sometimes, you will have two radiology reports one for screening and one diagnostic. In such a situation diagnostic codes should be sequenced first and than screening codes. For example a screening mammogram report and a dexa bone scan for osteoporosis. Osteoporosis code is sequenced first followed by screening mammogram code.

Dexa scans do not have any assessments most of the time so primary diagnosis shouled be the reason for doing dexa.