Anesthesia Coding Alert

Documentation would get an 'A,' but doctors might not go for it

If your group is struggling to determine what constitutes a -formal radiological report,- check out the American College of Radiology's (ACR) Standard of Communication at www.acr.org. The ACR's guidelines state the report should include four main components:

- Demographics (facility, patient and physician names, date, and type of exam, etc.)
- Relevant clinical information and ICD-9 codes as available
- Body of report (procedure, findings, potential limitations, clinical issues, comparisons)
- The physician's impression (conclusion or diagnosis). 
 
Using standardized template reports is acceptable if the template follows these guidelines.