Ii a patient has a fracture on a radiology report, however, the ER physician documents the final dx as sprain, should the coders be coding fracture?
Yes absolutely, coders should code the fracture. As you can see below, these coding clinics state any confirmed diagnoses on an outpatient (ER) radiology report should be coded. This applies to any outpatient claim, including SDS and OBS.
RATIONALE/CODING CLINIC REFERENCE:
Outpatient radiology coding
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017, Page 5, Effective with discharges: March 13, 2017
A patient presents to the hospital for outpatient x-rays with a diagnosis on the physician's orders of questionable kidney stone. The abdominal x-ray reveals "bilateral nephrolithiasis with staghorn calculi." No other documentation is available. Is it correct for the facility to report code N20.0, Calculus of kidney, based on the radiologist's diagnosis?
It is correct for the facility to report code N20.0, Calculus of kidney. Code to the highest degree of certainty. The radiologist is a physician, and when the x-ray has been interpreted by the radiologist, code the confirmed or definitive diagnosis. The Official Guidelines for Coding and Reporting, Diagnostic Outpatient Services Section IV. K., state, "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."
Also refer to Coding Clinic, First Quarter ICD-10 2013, Pages 28-29, Effective with discharges: March 27, 2013