AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 1; Ask the Editor - ICD-10-CM/PCS Coding Questions

Using the X-ray Report for Specificity

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? ...

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