Initial: This designation relates to when a service was rendered during the patient’s initial encounter for diagnosis and “active treatment” of the condition. To prevent confusion, it’s best to document this information as part of the diagnosis statement (eg, bucket-handle tear right medial meniscus) in the impression section rather than leaving it ambiguous and requiring the coder or computer-assisted coding program to detect the laterality from the exam title or clinical indication.Īll accident and injury ICD-10-CM codes must include a seventh digit to indicate whether an encounter is initial, subsequent, or sequela in nature. Meniscal tear must specify right or left knee.Tinnitus and otitis media must specify right or left ear.Breast, lung, and ovarian cancers must specify right or left breast, lung, or ovary, respectively.Note that for the following diagnoses, certain information must be documented: Based on a recent review of thousands of radiology documents, many radiologists seem to already be providing this documentation in many cases, but there are some symptoms and diagnoses that are still routinely missing this information. Just about every ICD-10-CM code that can have a right and left variation has one, so remember to add this information to anything that has a right and left option. Use these four pearls of wisdom as a starting point to help you prepare for the increased specificity that will be required on all radiology reports when the coding change occurs. Among other differences, ICD-10 requires much more specific documentation than the current ICD-9-CM version. As you’ve likely been briefed on many times, the new code set for assigning diagnosis codes, called ICD-10-CM, is currently proposed to go into effect October 1, 2014.
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