![]() ![]() Laterality - Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. Conventions, general coding guidelines and chapter specific guidelinesġ3. Here is a relevant excerpt from the Official Guidelines for Coding and Reporting: Do not code related signs and symptoms as additional diagnoses.” If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.”Īdvice from AHA Coding Clinic 1 st Quarter, 2017 Outpatient Laboratory, Pathology and Radiology coding states, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis documented in the interpretation. The same Coding Clinic also stated, “In the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. The question included examples regarding documentation of a sprain that the radiology report states is a fracture, and about site specificity, when the radiology report is more specific than the documentation in the medical record.Ĭoding Clinic answered the questions by stating that, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.” Will the same advice be true in ICD-10-CM?Ī: The AHA Coding Clinic 1 st Quarter, 2013 answered this question by stating that the same advice would apply to more specific coding in ICD-10-CM.Ī question sent to Coding Clinic asked about the specificity obtained from a radiology report and how it would be coded in ICD-10-CM. Is this still valid for ICD-10-CM?Ĭan you also address if the following advice still applies: An outpatient encounter for pain with no site mentioned and an x-ray is done, and we are instructed to code pain of that site of the x-ray. Previous advice stated that we can code the fracture. For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. A coder should not assume that pain is due to an old facture without supporting documentation or confirmation from the clinician.Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. X-ray reveals an old fracture but there is no other diagnosis of injury, can the pain be attributable to the old fracture?This scenario highlights a documentation issue, rather than a coding query and code assignment in this instance should be verified with the clinician. Paragraph 2 of this query cites a scenario where a patient is admitted with back pain following minor trauma (turning over in bed). If a fracture is documented as being associated with osteoporosis, then assign the appropriate code from category M80 Osteoporosis with pathological fracture. If in doubt, code assignment should be confirmed with the clinician.Osteoporosis causes severe weakening of the bones and can cause fractures, particularly lumbar fractures. To assign a pathological fracture code, the fracture must be either documented as 'pathological' or described as being 'due to a condition'. At the lead term fracture in the ICD-10-AM Alphabetic Index the term 'compression' is a nonessential modifier while the term 'crush' is not listed as either an essential or nonessential modifier.If there is no external cause of injury documented in the clinical record, and clarification is unable to be obtained from the clinician, assign X59 Exposure to unspecified factor as the external cause of injury code, following the pathway:įracture (circumstances unknown or unspecified) X59 Both crush and compression fractures, without further specification, should be coded to Fracture, by site. ![]()
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