Wiki ? do i need to obtain a corrected order

[Kimberley]

I work for an outpatient imaging facility......Order is for an MRI Lumbar W/ only. We perfromed W/WO......do I need to obtain a corrected order for W/WO? We have a discussion going on here in my office.

I have a print out from a seminar I went to a few years ago and I know the whole order policy changed. (not sure which seminar it came from) The is what they said and what I have been following:

Order states w/o:

Center performs w/o: No corrected order needed
Center performs w/: Corrected order is needed
Center performs w/ and w/wo: Corrected order is needed

Order states w/:

Center performes w/ only: No corrected order needed
Center performs w/o: No corrected needed
Center performs w/ and w/o: No corrected order needed

Order states w/ and w/o:

Center performs w/ only: No corrected order needed
Center performs w/o: No corrected order needed
Center perfroms w/ and w/o: No corrected order needed

Order does not indicate use or non-use of contrast:

This is equivalent to marking 'rads discretion'. NO CORRECTED ORDER IS NEEDED.

please let me know your thoughts.

Thanks

Kimberley Tober, CPC
Franklin, TN

 

[Kimberley]

Can someone give me some feedback on my question?

Thanks

 

[LLovett]

My first concern would be did this get pre-authorized before it was done or is that not an issue?

When I worked with radiologists previously they generally had the ability to do what they felt was necessary with out getting a corrected order for additional testing. They would actually order the additional tests under their own name if needed. The only issues we had were the prior auth requirements from some carriers.

Just my experience,

Laura, CPC

 

[Radcoder1313]

I code for an independent imaging center, too.
We require a new order and if the referring physician refuses, we would down-code it to with only.
Our rule of thumb is that you cannot code anything higher than what the order is for.