Question Hysterosalpingogram (HSG) documentation

BS&SC

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I have two OBGYNs who think they can use the radiologists report for their procedure note. My understanding is that they cannot. They must do their own note with patient consent, narrative and outcome of procedure. Am I missing the mark here?
 

csperoni

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Unless the radiologist is performing the procedure, the image interpretation is not sufficient. For starters, it is not created nor signed by your provider.
This is the equivalent of stating the pathology report is sufficient documentation to bill a biopsy.
Here's a lengthy, but very relevant and helpful article from ACOG. https://www.acog.org/clinical/clini...assessment/articles/2016/08/sonohysterography
I'm not big on treating all documentation as "what if in a worst case scenario", but performing a procedure with literally no documentation is a recipe for all sorts of problems.
 
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