Someone at our facility was told that a code could not be assigned from the body of the radiology report, only from the reason for the exam and the final impression. Can you tell me if that is correct, and, if so, where would we find those directions in our coding guidelines?
That is not true. Your primary diagnosis must relate to the reason for the exam, but other findings may be coded in addition, whether those findings are in the impression or in the body of the report.
That thinking may have evolved from guidelines for inpatient hospital coding where diagnoses from x-ray reports may not be coded unless the treating physician says they are clinically significant.
Here’s what the official guidelines say about inpatient coding:
Section III.B. Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. 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 provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
And here’s what they say about outpatient/physician coding:
Section IV.K. Patients receiving diagnostic services only
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.