Wiki Radiology Question

[KaylaRieken]

What kind of documentation is required for a KUB? We do the technical and professional component. Our doctor dictates in the office visit. We are getting denied for it. Any information would be greatly appreciated.

 

[csperoni]

What is the reason for the denial? There are some insurances that will not pay certain specialties for certain radiology codes, regardless of the documentation.
If the denial is for insufficient documentation, here is a good link about documentation for in office radiology from AAOS (ortho) but references ACR (American College of Radiology) requirements. https://www.aaos.org/aaosnow/2009/feb/managing/managing1/

• The name of the patient and other identification such as birth date and Social Security number
• The name of referring physician, if any
• The name or type of examination performed
• The date on which the X-ray was performed
• The name of the interpreting physician
• Authentication of non-handwritten note (ie, legible initials, legible signature, electronic signature, etc)

The body of the report:

• Procedures and materials
• Findings. Limitations. Clinical issues.
• Comparative data, if indicated
• The diagnosis
• A prescribing diagnosis should be provided when possible.
• A differential diagnosis should be provided when appropriate.

 

[KaylaRieken]

It said the documentation does not support the service.

 

[csperoni]

It said the documentation does not support the service.

Does the documentation have all the ACR requirements? If not, moving forward you need better documentation. If it does, then I would appeal.

 

[KaylaRieken]

So does the xray portion have to be on it's own report? Like I said they just dictate in the E/M visit.

 

[csperoni]

So does the xray portion have to be on it's own report? Like I said they just dictate in the E/M visit.

This was addressed in the link to the AAOS article I originally provided. Basically, most carriers do not require a separate document. Regardless, it must still contain all the elements.