Wiki Ultrasound Orders

[abrookner232@gmail.com]

Hello,

Is there any formal policy as to whether the orders in the medical record must match the indication listed within the ultrasound report? We are having issues with our ultrasound techs using generic diagnosis codes rather than the diagnosis codes provided by the referring provider, and I would like to present them with official instructions that the indication must match the order. Are there any resources for this?

Thank you!

diagnosis codes, diagnosis coding

 

[nielynco]

Hello,

Is there any formal policy as to whether the orders in the medical record must match the indication listed within the ultrasound report? We are having issues with our ultrasound techs using generic diagnosis codes rather than the diagnosis codes provided by the referring provider, and I would like to present them with official instructions that the indication must match the order. Are there any resources for this?

Thank you!

No there is not. In general, the reason the ultrasound if ordered by the provider should be reported unless there is a more specific finding during the ultrasound. As a matter of practice, the physician would be considered the most qualified to identify and then interpret the ultrasound findings, not the ultrasound tech. The assignment of the actual ICD10 diagnosis code should always be as specific as possible and match the findings.

diagnosis codes, diagnosis coding