Reason for Exam


Coconut Creek, FL
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I am a provider documentation specialist for a large physician practice management company. In radiology, we very frequently get requests from the Emergency Department for studies with the reason for exam/clinical history being "Trauma" with no other information. My radiologists know that when they dictate trauma as the reason for exam and the study is negative, that study will end up with an unspecified diagnosis code and after October 1st, may not get paid. We are working with our facilities to improve this but it is slow going.

Here is a common scenario:
Order from the ER for a CT Brain with a clinical history of "Trauma". The radiologist dictates a normal study with no positive findings.

Does anyone have any suggestions for my radiologists? Thank you! kd
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Out of curiosity, if an order for a CT of the Brain with "history of trauma" comes through and the results show no positive findings, what unspecified code is chosen? Unspecified brain injury? I only ask because if the CT is unremarkable, then I don't see how an unspecified brain injury diagnosis would remain an option.

My initial thought when I read your post was, since the patient is present (obviously) when the CT is done, couldn't signs and symptoms be documented at the time of the CT? If the patient is unconscious, you could still document visible injuries, such as lacerations. If any of that information could be included in the report, then they can be used in place of an unspecified diagnosis, which might work in your favor. Along those same lines, using signs and symptoms is more appropriate if there is no confirmed diagnosis, which is the case if the CT is negative.