leagle
Contributor
I need advice on what I should be using to code when reviewing my radiologist's reports for administering contrast for an MRI and when barium swallows are done in conjunction with a speech therapist. For the MRIs, I have a "reason for exam" and his impression is always "technically successful blah blah injection of contrast into X joint." 9/10 times they are to look for tears. Should I be reviewing the MRI report also for a confirmed tear dx? Or should I always just code the reason for exam? I struggle with this because I feel I should since the full report is done at time of coding, but then I think but I'm only coding for what my doctor did and it wasn't confirmed when he did his part. As for the barium swallows, he will write usually the same thing for each trial....premature spillage, flash penetration, etc and then in the impression say "results as described above" and "please see speech therapy report for more details." Ok, again, should i just code off of his report? Or should I review the SLP's note also?