The 3 Most Common Misconceptions for Clinical Indications Documentation


In today’s environment of declining reimbursement and increasing costs, it is critical for radiologists to relentlessly strive to optimize their reimbursement and overall practice performance. Radiologist documentation is the key to reimbursement, so it is important to choose your words carefully.  While the topic of radiologist documentation is broad and complex, avoiding common clinical indication documentation errors is an area of “low hanging fruit” that can be addressed quickly and efficiently.

Know your audience. Radiology reports are reviewed by multiple different audiences, including referring physicians, coders, insurance companies, auditors, and occasionally law firms.  Each audience focuses on different information. This article addresses the needs of the medical coder and payer audience.

 The Problem. The language used by radiologists to describe Clinical Indications is often unclear, vague and incomplete, which causes avoidable denials and payment delays.  The codes assigned must mirror the radiologist’s documentation.  Coders are not permitted to make guesses or assumptions to make up for lacking documentation. This problem is easily correctable with simple modifications to the radiologist’s documentation.

 Importance of Clinical Indications. When claims are initially submitted for reimbursement, only the codes assigned are submitted, not the radiology report.  The codes abstracted by medical coders and assigned to the claim provide a standardized means of communicating the story to the payer.  Procedure codes (CPT) describe what you did while diagnosis codes (ICD-10-CM) explain why you did it. More specifically, clinical indications explain why the procedure was performed.  Clinical indications must clearly and accurately describe observable signs and symptoms exhibited by the patient that indicate why the procedure was medically necessary.

 The Required Resource. HIPAA regulations require physicians to follow the ICD-10-CM Official Guidelines: “Adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).” In addition to the book itself, here is a link to 2021 ICD-10-CM updates that will also be helpful in understanding the guidelines:  Click here


The 3 Most Common Misconceptions for Clinical Indications Documentation

1. Proper Use of the Word “History”. A common misconception is whether the term “history” can be used to identify a previously diagnosed condition that still exists. Do not use the word “history” when the patient has been previously diagnosed but is still currently receiving treatment. For coders, there are two sets of diagnosis codes, one for “current conditions” and a separate one for “past conditions”, or history.  For coding purposes, history is defined as a medical condition that no longer exists and the patient is no longer receiving treatment.

Here are a few examples showing how the codes change between a current condition verses a past history:

Prostate cancer C61 Personal history prostate cancer Z85.46
Pulmonary embolism I26.99 Personal history of pulmonary embolism Z86.711
Type 2 diabetes mellitus w/ foot ulcer E11.621 Personal history of diabetic foot ulcer Z86.31

Reference:  ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Ch. 2, h., Ch. 21, 4 ICD-10-CM Guidelines state “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving treatment…”, so if the patient has a previously diagnosed condition that still exists, even though it was previously diagnosed, don’t use the word “history” to describe it.


2. The Word “Or” – Don’t Use It. A common misconception is that if the word “or” is used to describe multiple clinical signs/symptoms and indications, that one or all of them can be coded.

When documenting clinical indications, do not use the word “or.”  Using the word “or” is comparable to giving a waiter an order of fish OR steak OR chicken. Until you specify which specific item you want, nothing will happen.  Document confirmed and observable signs, symptoms and indications. For example, when documenting the clinical indications of an extremity venous Duplex scan, identify known symptoms.  Do not document, “Right lower extremity pain or edema.”  Be specific and use known symptoms.

Reference:  ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section IV., C.

“For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, conditions, problems, or reasons for the encounter.”


3. Uncertain Diagnosis. A common misconception is that there are codes for “suspected” conditions. Diagnostic tests are often ordered to “rule-out” a condition. There is nothing wrong with including that information when ordering a study, but you must also include the observable signs/symptoms that prompted “suspected” condition.

Guidelines require diagnosis code assignments to be based on the highest degree of certainty of the signs/symptoms.  Since there are no diagnosis codes for “suspected” conditions, it is imperative to provide the signs/symptoms that prompted the medical necessity for the test/procedure.

Scenario 1:

Clinical Indication:  Rule-out pneumonia

Study:  Two-view chest x-ray

Findings:  Normal

ICD-10-CM Code: ???

Scenario 2:

Clinical Indications:  Cough, shortness of breath, rule-out pneumonia

Study:  Two-view chest x-ray

Findings:  Normal

ICD-10-CM Code:  R05 cough and R06.02 shortness of breath

Scenario 3:

Clinical Indications:  Cough, shortness of breath, rule-out pneumonia

Study:  Two-view chest x-ray

Findings:  Pneumonia

ICD-10-CM Code:  J18.9 pneumonia

Reference:  ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section IV., H. “Do not code diagnoses documented as ‘probable’, ‘suspected’, ‘questionable’, ‘rule out’, ‘compatible with’, ‘consistent with’, or ‘working diagnosis’, or other similar terms indicating uncertainty. Code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”


Referring/Ordering Physicians and Hospital Information Systems Are Often Part of the Problem. Technically it is the responsibility of the referring/ordering physician to provide complete clinical information to justify the medical necessity for the test/procedure.   This information typically flows to radiologists through the hospital information systems, which may cause certain bits of information to get modified or deleted. It’s a great idea for radiologists to check with their hospital staff when signs/symptoms information is vague or incomplete. Additionally, radiologists should  build rapport with referring physicians by requesting clarification and providing feedback to them regarding their order information.  This can be a very sensitive matter and must be handled very carefully and diplomatically. While CMS is testing policies such as the looming Medicare Appropriate User Criteria (AUC)-based Clinical Decision Support (CDS) requirement (currently expected to be required effective January 1, 2022) to remedy these issues, for now, working with hospital staff and referring doctors can help reduce the chances of errors.

 Summary. Documentation for clinical care, proper coding and reimbursement are equally important. Radiology practice success is dependent upon quality radiologist documentation, which requires an understanding of the ICD-10-CM Official Guidelines. The documentation of Clinical Indications is a common area for documentation errors which are easily avoidable.  Every word counts. Provide a clear understanding of what procedure was performed, why it was the procedure performed, and why it was medically necessary. This will allow claims to be rapidly and accurately coded and paid, and ultimately improve overall practice performance.

  • Only use the term “history” when describing a patient’s past medical condition that no longer exists and is no longer receiving treatment.
  • Avoid using the word “or” when providing reasons for the procedure or study.
  • When a condition is not yet confirmed, include observable signs, symptoms, abnormal test results or other confirmed reasons for the procedure to be performed.
  • Communicate with your hospital staff and referring providers to address any shortcomings in order information.
  • Choose the words in your documentation carefully, as great documentation leads to correct coding and improved reimbursement.




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