Wiki Ultrasound Orders

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abrookner232@gmail.com

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Hello,

Is there any formal policy as to whether the orders in the medical record must match the indication listed within the ultrasound report? We are having issues with our ultrasound techs using generic diagnosis codes rather than the diagnosis codes provided by the referring provider, and I would like to present them with official instructions that the indication must match the order. Are there any resources for this?

Thank you!
 
abrookner232@gmail.com said:
Hello,

Is there any formal policy as to whether the orders in the medical record must match the indication listed within the ultrasound report? We are having issues with our ultrasound techs using generic diagnosis codes rather than the diagnosis codes provided by the referring provider, and I would like to present them with official instructions that the indication must match the order. Are there any resources for this?

Thank you!
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No there is not. In general, the reason the ultrasound if ordered by the provider should be reported unless there is a more specific finding during the ultrasound. As a matter of practice, the physician would be considered the most qualified to identify and then interpret the ultrasound findings, not the ultrasound tech. The assignment of the actual ICD10 diagnosis code should always be as specific as possible and match the findings.
 
Thank you. For an office with both OB/GYN and Perinatology, if the OB sends the patient to Perinatology to receive testing (ex: nuchal translucency), what guidance can I provide them that they still need to create an order? Some seem to think because they are sending the patient internally, that an order is not needed.
 
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If you are an outpatient hospital department, (i.e. provider based clinic) then there is an order expectation under Conditions of Participation 42CFR 482.54

I would also check your state licensure scope of practice for US techs. Unless you are a Qualified Health Professional (MD, DO, DMD, DDS, APRN or PA), you may not assign a medical diagnosis code. Besides causing potential payment issues, this is unethical.

If being performed within a practice, and billed incident-to the providers' service, you cannot assign a new diagnosis code. They have to follow the provider's treatment plan (and subsequently the order). However, this appears to be a performance issue. I would take it up with the imaging department leader.
 
Sorry to drag this on, I just want to be clear. When addressing the imaging department leader, are there any guidelines I can give them? How can I make it clear that they should not be scheduling/seeing patients unless there is an order? I think it should be obvious an order is needed, but there has been pushback on both ends so it would be helpful to have any formal guidance to give both the provider and imaging department.
 
To recap: If this is an outpatient department, federal rules (42CFR) require it. Look up the Code of Federal Regulations, Title 42.
If it's a practice, billing incident-to a provider, (incident-to rules are in the CMS Coverage IOM manuals), the order supports the providers' intent (treatment plan) and diagnosis.

At the very least, no US tech should be assigning a medical diagnosis. (check state licensure), but also this is addressed in the ICD-10-CM Guidelines "The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or anyqualified healthh care practitioner who is legally accountable for establishing the patient’s diagnosis.

interestingly, SDMS (society of diagnostic medical sonography) states the following under practice scope :
4.1.5Does not perform sonographic examination or procedures without a medical order by an authorized healthcare provider, except as authorized in an educational (e.g., sonography educational program, in-service training, and continuing medical education activity) or research setting.
 
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