Ask Dr. Z

What are the coding rules for where we can get ICD for IR procedures? Our new educator only wants us to use ICDs off the IR report and/or the order. Are we not allowed to use notes from the ordering provider like H&P or long-term facility notes sent with the patient for the radiologist to review? If the H&P states PAD with claudication and the order and final IR report only state PAD, we end up coding only PAD, which is not covered. This also happens a lot with fistulograms for dialysis. The report and order state only ESRD. BUT the H&P have HTN, DM, heart failure as part of patients history. Seems like the more detail we code the more accurate the coding, so do we need to query for all details, or can we use H&P when coding IR? I realize this is an education of provider issue, but we are sending out way too many queries and all that does is irritate the provider.