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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Article Overview
This article discusses coding questions that arise when radiology reports for outpatient encounters include incidental findings not otherwise documented in the encounter record. It focuses on how existing guidance and prior Coding Clinic advice are interpreted in the emergency department setting, and on the documentation responsibilities involved when report findings appear unrelated to the reason for imaging. The material is relevant to coders, CDI staff, and clinicians working with outpatient and ED diagnostic reporting.
Why This Topic Matters
Incidental findings can create uncertainty in outpatient coding and documentation workflows, especially when imaging results include additional abnormalities that are not reflected elsewhere in the record. Understanding the scope of applicable guidance helps support more consistent coding review and documentation practices.
What You Will Learn
- How incidental findings on outpatient radiology reports are discussed in coding guidance.
- Why emergency department documentation is important when imaging identifies additional findings.
- How prior coding advice may be applied in the context of outpatient diagnostic imaging records.
- The documentation considerations that affect whether a radiology finding is reflected in the final encounter record.
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation integrity specialists
- Emergency department clinicians
- Revenue cycle staff
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