Wiki Radiology Documentation question

[RKAsh]

Hi all -

Does any one have any insight if in Radiology documentation is it necessary for the provider to repeat the ordered exam (films) in the body of the note?

Just trying to get the basics

 

[jbaird]

I'm not sure what you are asking, but you may want to go to the ACR website and see if you can find what you need there. The report should have a title indicating what exam was done and the radiologist or physician would need to give a technique for more detailed exams. The report should include the number/type of views for plain films, whether the exam included contrast, or any other details pertaining to that type of exam to allow the coder to properly code and bill for the exam.
Here's a link to the ordering of diagnostic tests rules:
http://www.acr.org/Hidden/Economics...onontheOrderingofDiagnosticTestsRuleDoc8.aspx

 

[jbaird]

Here is a link to the "ACR PRACTICE GUIDELINE FOR COMMUNICATION OF DIAGNOSTIC IMAGING FINDINGS":
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/comm_diag_rad.aspx
This may have been more what you were looking for.