Wiki Procedure missing required elements

[stephaniec5]

Had a discussion today regarding when is it appropriate to send a report back to the radiologists for missing documentation. I am under the impression that it is not appropriate to do this and the record is to be coded based off of the available information that is in the report. Found out the previous billing company used to set aside these reports to return to the radiologists to have an addendum completed. Examples I have are for ultrasound and duplex studies.

If an ultrasound was missing elements for a "complete" study it would be returned to obtain this additional information instead of it being coded as a "limited", same thing for duplex studies when all that is originally noted is the color flow but missing the other documentation requirements.

I am trying to work with the radiologists on the quality of their documentation but while I do this need to know if it's okay to return for the addendum or it is coded "as is"

 

[senpai_j]

The golden rule I follow is, "If it's not documented, it wasn't done." Sometimes it's a judgement call about whether to query. It's also a matter of the workflow of your group. Personally, if the physician is trying to bill a complete US, but they only talk about one structure, I'd down code it and move on. However, if they talk about most of the structures and are only missing one I'd probably query.