Wiki ERCP Question

[tfrick2]

Here's my scenario:

A GI doctor does an ERCP on a patient. His dictated report only mentions the biliary tract and gallbladder being visualized. However, the radiologist's dictation mentions that the pancreatic duct is visualized as well.

Does the GI doctor needs to dictate an addendum to include the pancreatic duct, or is that considered to be incidental on the part of the radiologist? Another question would be, does the radiologist include the pancreatic duct in consideration of what procedure to bill?

I hope this makes sense! I posted this same scenario on the GI forum as well, to get some opinions from that side.

Thank you for your help!

Tracy, CPC, CPC-H

 

[donnajrichmond]

First question is why is the radiologist dictating if the gi doc already has? But if he is going to he needs to document all that is images, regardless of what the gi doc does. His bill reflects what he did. Then you have to also add 52 modifier if the Rad wasn't in the room during the procedure.