MRA Thought of the Day – The Radiologist’s Role in ICD-10-CM Documentation

Suzanne Neve, RHIA, CTR - Director, Cancer Registry Medical Coding Leave a Comment

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Lynn Salois, RHIT, CCS, CDIP, Director of Coding

A unique friendship between coder and radiologist is on the horizon. It is actually not so unique, but rather very logical.

ICD-10-CM fracture coding requires anatomical specificity, simply stated, which bone is broken and what part of the bone is broken? For example, fracture of subtrochanteric neck of the right femur. Documentation of this detail is very often located in the radiology report.

However, most radiologists are not aware this level of specificity is required to code all fractures in ICD-10-CM.

Here are my thoughts…

Educate radiologists about the documentation requirements for fracture coding: laterality, open, closed, displaced, non displaced, bone and specific portion of the bone and type (i.e., comminuted, spiral, oblique, transverse).

Then work with the attending physician to ensure the documentation is carried over to the progress notes and discharge summary.

What are your thoughts?

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