Nobody that I work with seems to know the answer to this question. We do both diagnostic and interventional radiology. The problem is with patients who come in through the ER. I don't know if it is because everyone is in a 'state of emergency,' but we never have an order on file for these folks. What's worse, the indications line is usually no help at all in coming up with a primary diagnosis. It might say something like 'chest x-ray,' or something else that is not code-able. It is my impression that they are just doing a chest x-ray 'just in case.' Anyway, finally I arrive at the question: Is it appropriate, kosher or cricket to take signs and symptoms from the triage sheet to use as a primary DX when you have absolutely nothing else to code? The triage sheet is the nearest thing we have to an order. Is this the sort of thing we could get 'dinged' for in an audit?
Diagnosis from triage sheets
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