mmunoz21
Networker
Hi,
I'm trying to locate any CMS documentation where it states that the actual Radiology Report as with any other specialty should stand alone in an audit. For example- Head CT scan done 2/1/2017 Reason Fall- no other DX is given- when an auditor is looking at this report they do not go back to check the orders, or the E/R record, or prior visits the patient had with the ordering provider to get a more definite Diagnosis other than Fall; nor should a coder be expected to go through all other documentation to obtain the more appropriate diagnosis code-to my point that each visit or test Must Stand Alone against an audit; but where can I obtain any information regarding "stand alone documentation" so I can provide it to the providers? thank you
I'm trying to locate any CMS documentation where it states that the actual Radiology Report as with any other specialty should stand alone in an audit. For example- Head CT scan done 2/1/2017 Reason Fall- no other DX is given- when an auditor is looking at this report they do not go back to check the orders, or the E/R record, or prior visits the patient had with the ordering provider to get a more definite Diagnosis other than Fall; nor should a coder be expected to go through all other documentation to obtain the more appropriate diagnosis code-to my point that each visit or test Must Stand Alone against an audit; but where can I obtain any information regarding "stand alone documentation" so I can provide it to the providers? thank you