Radiology Forums

LorraineB · Joined: 29 Jan 2008 Posts: 1

Hello,

I am unable to locate a reference with regards to Radiology documentation. I have an auditor who is instructing my coders that if the views are not documented within the actual radiology report, they must code the lesser number of views. For example, the radiologist selects 73080 and the heading of the radiology report states, "Elbow, minimum three views" and the radiologist procedes to document the findings.

The auditor is stating that since he/she doesn't states the three views in the body of the report, then 73070 should be used.

I need a documented source that states this because I do not agree.

Thanks, Lorraine

papa · Posted: Fri Feb 01, 2008 10:38 am Post subject:

not sure about actual documentation, but if i'm understanding this right, if the code says minimum 3 views, the doc just dictates it without saying what kind of images there are?

usually, our docs say what kind of films they're looking at before anything else in the report.

example:
elbow, min. 3 views
AP, LATERAL, AND BOTH OBLIQUE VIEWS WERE OBTAINED ON........

maybe i'm misunderstanding the question....

papa
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sbuck · Joined: 22 Apr 2008 Posts: 7 Location: Stuart, FL

You won't find what you are looking for in black and white.

I can tell you that there are issues with coding based on the title or header of a report--often these are auto-populated based on order entry, so the exam selected may not match with the exam performed and beyond that even what elements are actually described in the findings.

It is always best to be as specific as possible. I advise our clients that the body should match the title.

Don't give outside auditors for payers even the slightest reason to try to get you money back!
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