Radiology Report must stand Alone against an audit

mmunoz21

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Hi,

I'm trying to locate any CMS documentation where it states that the actual Radiology Report as with any other specialty should stand alone in an audit. For example- Head CT scan done 2/1/2017 Reason Fall- no other DX is given- when an auditor is looking at this report they do not go back to check the orders, or the E/R record, or prior visits the patient had with the ordering provider to get a more definite Diagnosis other than Fall; nor should a coder be expected to go through all other documentation to obtain the more appropriate diagnosis code-to my point that each visit or test Must Stand Alone against an audit; but where can I obtain any information regarding "stand alone documentation" so I can provide it to the providers? thank you
 

thomas7331

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The only place that I've been able to find where CMS addresses this is in section 100.1 of Chapter 13 of the Medicare Claims Processing Manual (link below), where is states "A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service." This section, however, is specifically addressing x-rays and EKGs done in the emergency room so doesn't necessarily apply to all situations, though it would seem like common sense that it should.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf

I've never been able to find anything more general on this topic from CMS, but another recent post of this forum did provide a link to the Radiology professional society's standards for what should be included in any report for interpretations of images - if you do a search here you can probably locate that source too.
 

mmunoz21

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Thank you for the response- I've been researching to see where I can find any information where the coders are allowed to code from "Ancillary Services" when the Radiology Report is vague...
 

thomas7331

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Specific to selection of the diagnosis for radiology tests, this guidance used to be included in the Manuals which I thought was very good:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ab01144.pdf

Unfortunately, it was apparently deleted from the Manuals with the introduction of ICD-10 and not replaced with updated guidance, so I'm not sure if it's still current. I'll watch your post to see if anyone has anything more current.
 
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