Booking diagnosis VS Findings

If a referring physician provides a booking diagnosis of torn meniscus, stroke etc. and after MRI (IDTF) is performed the radiologist does not find evidence of torn meniscus or stroke etc. can the MRI facility bill with the booking diagnosis?

If patient verbally provides diagnosis, can the MRI (IDTF)bill with the diagnosis provided by the patient if not documented by the referring or not found by the radiologist?

If referring physician provides verbal dx or symptoms, can the MRI (IDTF) bill with verbal dx or symptoms?

If MRI (IDTF) uses a software that checks medical necessity and the dx used for medical necessity passes as a payable dx but when the MRI was done the radiologist did not find any evidence of the booking dx, can the MRI facility bill with the booking dx that passed medical necessity, even if there were no findings of that dx?


  • Yes, code the referring MD's diagnosis, any findings can be (note - not *must* be) reported in addition.

    Here's what the ICD-10 Guidelines say:

    "K. Patients receiving diagnostic services only
    For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses."


    "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. Do not code related signs and symptoms as additional diagnoses."

    Leslie Johnson, CPC

    Know what you know & Know Why you Know It!
  • edited May 2017
    But . if referring says for example STROKe and there is no stroke or
    cancer and the dx is not cancer DO NOT CODE THIS. Many times referring gives
    the differential diagnosis and not the known dx. You cannot code what is
    not shown to be correct. You also should not code what patient tells you
    unless you confirm with referring md.

    In the second paragraph below, you code the findings related to the
    indication - why was the exam done.
    Often there are findings but they are not related to reason for exam, they
    can be coded but not as the primary code.

    Sharon Cohen, RHIA, MSM
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