How to Dictate and Do ICD9 Coding in Neuroradiology

by
Per-Lennart Westesson, MD, PhD, DDS
Department of Radiology
University of Rochester Medical Center

Background:

All insurance companies require that a diagnostic code is applied to each examination in order for it to be reimbursable. The diagnostic code reflects the indication for the study. Thus, if a patient presents with headache and there is a clinical suspicion for subarachnoid hemorrhage and a head CT scan is requested, we should use the ICD9 code 784.0 for headache. If a patient with the same presentation turns out to indeed have subarachnoid hemorrhage, we would use the ICD9 code for subarachnoid hemorrhage namely, 430.

On each dictation station in neuroradiology there is a blue book with lists of the appropriate ICD9 codes for most of neuroradiology studies. There is also a copy of the international diagnostic code book in both CT and MR reading rooms as a resource to look up more unusual codes.

Order in which to dictate the codes:

We recommend that you dictate the information in the following order:

1. Patient name
2. Accession number
3. Date and type of study
4. ICD9 code. If multiple studies are dictated each has to have an individual ICD9 code. Thus each accession number should have its own ICD9 code.
5. Any standard report that is to be used, such as CT1, CTN10 etc.
6. Clinical information include patient name, sex and age as a verification for the correct patient
7. Procedure. If standard procedure included, refer to that one once again.
8. Findings
9. Impression

It is important that the impression is really your and the attending's impression of the case. It is, in general, not appropriate to repeat the findings. The impression should be a message to the clinician what you think it is and if necessary what you think the alternative differential diagnosis could be. Thus, "acute infarct right globus pallidus" would be a good type of impression.

How to dictate combined reports:

Maxillofacial and Neck CT

Clinical Information:  (Covering all studies requested)
Maxillofacial CT Procedure:
Maxillofacial CT Findings:
Neck CT Procedure:
Neck CT Findings:
Impression:  (Covers both studies)

Head, Orbit and Face CT Scan

Clinical Information:  (Covering all 3 studies)
Head CT Procedure:
Head CT Findings:
Orbit CT Procedure:
Orbit CT Findings:
Maxillofacial CT Procedure:
Maxillofacial CT Findings:
Impression:  (Covering all studies)

Orbit and Face CT

Clinical Information:  (Covering both studies)
Orbit CT Procedure:
Orbit CT Findings:
Maxillofacial CT Procedure:
Maxillofacial CT Findings:
Impression:  (Covers both studies)