Wiki Why was I marked wrong? (Practicode Case ID: OPD7420)

[Elund]

The relevant documentation:

Spoiler

CT Head: (COMPARISON: None


There is no evidence of a focal mass lesion, mass effect upon the


brain parenchyma or intracranial hemorrhage. No abnormal extra-axial


fluid collections are identified. The ventricles are normal in size


and the configuration for the patient's age. Bone windows are normal.


There soft tissue swelling over the nasal bridge and right frontal


bone.


IMPRESSION:


1. Normal noncontrast head CT.


Paul Kramer, MD


Electronically signed by PAUL KRAMER, MD 5/24/20XX


The study was interpreted contemporaneously by me.

Why isn't the CT scan reported?

 

[sls314]

The relevant documentation:

Spoiler

CT Head: (COMPARISON: None


There is no evidence of a focal mass lesion, mass effect upon the


brain parenchyma or intracranial hemorrhage. No abnormal extra-axial


fluid collections are identified. The ventricles are normal in size


and the configuration for the patient's age. Bone windows are normal.


There soft tissue swelling over the nasal bridge and right frontal


bone.


IMPRESSION:


1. Normal noncontrast head CT.


Paul Kramer, MD


Electronically signed by PAUL KRAMER, MD 5/24/20XX


The study was interpreted contemporaneously by me.

Why isn't the CT scan reported?

Who's note are you coding? The radiologist or another physician (ER, specialist, etc).

You'd only code the professional component of a CT scan for the radiologist.

 

[sls314]

See the explanation I gave on a previous case - the same applies here: Wiki - Why was I marked wrong? (Practicode Case ID: OPD7424)

 

[Elund]

Thanks. It seems that the reporting physician is different from the one who signed the radiology report. I was not expecting that.