• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Ultrasound interpretations

Create Wiki
J

jhanmer83

Networker
Messages
34
Location
Hendersonville, NC
Best answers
0
I have a compliance question regarding ultrasound documentation and where the interpretations get documented. Currently at the clinic I work at the ultrasound techs document the technical data on the ultrasound reports with their findings, but the providers document their impressions/interpretations in amongst the office visit notes. It was brought to my attention recently that the providers have no access to be able to alter or change anything that the ultrasound techs document in their part of the ultrasound report and they can't add their impression directly to the report due to how the system is set up. I know that all imaging requires a separate report and my thinking is the impression is an element of that separate report and must be separate from other clinical documentation, especially for instances when a patient only allows the release of their imaging studies and not their office visit notes. Is the way they're documenting acceptable, or should they be doing a separate note linked to the ultrasound encounter with their impression/interpretation?
 
I found this searching online:

Written Interpretation & Report
A final formal written report must be included in the chart. A sonographer’s worksheet or a brief "ultrasound performed" note is not sufficient. The report must detail: [1, 2, 3, 4, 5]
  • Type of exam: Whether it is a complete study (requiring visualization of all elements defined by CPT) or a limited/focused scan.
  • Findings: Detailed description of the organs/areas evaluated, including measurements and any abnormalities.
  • Impression: The provider's final diagnosis and interpretation of what the findings mean.

Written Report/Interpretation​

A written report of all POCUS (point of care US) studies needs to be included in the patient’s chart. This is arguably the most time-consuming step and is where many providers leave potential reimbursement on the table. A critical action is to proactively sit down with your billing department and/or EMR experts to create macros or templates with all of the required elements. These templates can be pulled up quickly and easily while on shift to ensure that systematic and complete documentation is included in the chart every time.

Minimum content of each template should contain include the study being performed, the views obtained, the respective findings, and a separate final interpretation of the study. Additionally, the distinction of a complete or limited (focused) exam should highlighted. Explaining the required elements differentiating between these two classifications is beyond the scope of this article. However, if being performed in a busy emergency department to answer a specific diagnostic question, the safe bet is to presume that you are performing a limited exam.
Here is the link for the above:
 
You must log in or register to reply here.
Top