AHA Coding Clinic® for ICD-9 - 2010 Issue 3; Ask the Editor

Incidental Findings on Radiology Reports for Outpatient Encounter

We are requesting guidance on coding incidental findings found on radiology reports during outpatient encounters. For example, a patient is seen in the emergency department (ED) for chest pain and a computed tomography (CT) of the chest and abdomen are performed. The CT of the abdomen was performed to rule out any type of gastritis-associated chest pain. The impression on the CT is normal except for “single renal cyst.” The cyst is not documented anywhere else on the ED record, nor does it appear to be related to the reason why the CT was initially performed. Are we correct in interpreting existing guidelines and previous Coding Clinic advice that findings from x-rays performed on patients in the ED should not be coded except to gain greater specificity for an already diagnosed condition? Do you agree that it is the responsibility of the ED physician to document the relevance and pertinence of each diagnosis in his/her final impression? To us, this is different than the guidelines we follow for coding outpatient diagnostic tests when the patient presents to the ancillary department specifically for a particular test and interpretation. There is no other physician involved to ‘coordinate’ the care, treatment, and diagnosis of the patient like there is when the patient presents to the ED and gets these tests performed. ...

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