Wiki echo documentation

[mmagness]

Does anyone know if there is a "requirement" for the echo documentation to include the velocities/ pressures for a echo with doppler/color flow? Would it be sufficient to say:

"Techinically difficult 2-D M-mode color flow pulse wave and continuous wave examinations are performed. Doppler interrogation reveals moderate mitral regurgitation, moderate tricuspid regurgitation, mild pulmonic insufficiency, and mild aortic insufficienncy"

Wouldn't the pressures have to be done to indicate the above findings? We had someone within our office that has questioned the lack of individually listed velocities/presures...

Thanks,
Molly

 

[deeva456]

hello,

We have several cardiologists in our office and each one dictates their reports differently; however, they do list the measurements. I dont know if there are specific guidelines as to what needs to be documented. But, if the measurements are not in the report, how can the MD determine if the patients condition has worsened? What would they use to compare to a previous echocardiogram that was done? In our cardiology practice we have many patients referred to us by the patients PCP for pre-op evaluations, physicials etc. and w/o properly documenting the finding then we are not providing quality care. I would check out the LCD lists as it gives more information about echocardiograms.


However, you can use your example in the final assessment or summary of the exam.

Techinically difficult 2-D M-mode color flow pulse wave and continuous wave examinations are performed. Doppler interrogation reveals moderate mitral regurgitation, moderate tricuspid regurgitation, mild pulmonic insufficiency, and mild aortic insufficienncy"

good luck,

 

[mmagness]

We have the measurements listed... The question in more along the lines of pressures and velocities... I don't see anything that says that they have to be listed but there was a question in our office on whether they should be in the report in addition to the measurements...