Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, in ICD-9-CM if the record describes a fracture of the leg and the radiology report identifies a specific site of the leg, we are allowed to code that more specific site. Will this be true also in ICD-10-CM as well? For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Previous advice stated that we can code the fracture. Is this still valid for I-10?
Can you also address if the following advice will apply in ICD-10: 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. Will the same advice be true in I-10?
The same advice would apply to more specific coding in ICD-10-CM. 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.
Additionally, in the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the finding 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.
In the outpatient setting, if the diagnostic tests 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(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.