I review emergency department charts on the facility side and I often have to review charts from our denials department. I have a case where an MRA of the neck was ordered with a dx of arm numbness and TIA. The nurse is asking if TIA can be added in the Attending’s final impression to support medical necessity for the MRA. The attending reviewed the findings from the radiologist "Diffuse white matter signal abnormalities in the bilateral cerebral cortices, most likely related to chronic microvascular disease. There are no signs of acute ischemia, hemorrhage, or mass." And, the attending documented that the MRA was negative in his progress note and left his final impression of arm numbness.
These are my questions:
1. Can the dx of R93.0, abnormal findings on diagnostic imaging of skull and head, NEC, be reported. Please note: the attending does not address these findings and states the MRA is negative.
2. Can the TIA dx be reported if it is only found on the order? There are no other signs and symptoms in the medical record to support medical necessity for the MRA of the neck.
3. Should I query the provider?
Medical Billing and Coding Forum
