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X-ray dicated vs X-ray order

  1. #1
    Exclamation X-ray dicated vs X-ray order
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    Good Afternoon,

    I am being told by our compliance officer that an x-ray dictation does not have to match an x-ray order given. The example I have is that our physician dictated in the note that he did an AP and Lateral of the right tib/fib but when I went to code/bill this out I saw that the order was for the right ankle. I was told that I should bill this out as it is dictated and that the order didn't have to match the x-ray taken. I found documentation online that completely contradicts what they are telling me. I disagree with their answer but am forced to code this way. I would like another compliance officers opinion on this.

    Thank you in advance!

  2. #2
    Unhappy no takers?
    I'm surprised that not one compliance officer is willing to answer this question. It seems that is what I find across the board no matter where I go. It doesn't have to be written in stone; I'm looking for "opinions" on the subject from people who are supposed to be the experts. I'm not a compliance expert so I came here. Can anyone please offer their opinion on my question?

    Thank you,

  3. #3
    This question, as pertains to covered services for Medicare patients, is addressed by CMS in the Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 80.6- Requirements for Ordering and Following Orders for Diagnostic Tests. As a general rule, in order to be a covered service, testing facilities or interpreting physicians are required to perform and bill for only the test that was ordered, but there are certain exceptions and documentation requirements that must be met in those cases. This section of the manual is somewhat lengthy, so I won't attempt to copy or summarize it in a post, but you can find the regulation here:

    Hope this helps some.
    Thomas Field, CPC, CEMC

  4. #4
    Hi Thomas,

    Thanks for replying. I saw all of that in my research and in my case the physician ordered a specific x-ray (ankle) but the physician who dictated the note "saw it as a tib/fib" x-ray and therefore dictated it was a tib/fib x-ray." The guidelines say that the radiologist can change the order if the first x-ray didn't show what they were looking for or if they felt they needed more info by doing something else. This is not the case here. The physician who read the x-ray just dictated the wrong x-ray in the note and I'm being told to bill that x-ray out even though it was not what was ordered. The guidelines don't apply in this case in my opinion. I can understand if the x-ray was changed but it wasn't, it was just incorrectly dictated. How is that legal? If I billed out the tib/fib x-ray and it was audited for some reason wouldn't they question why I billed out the wrong x-ray from what was ordered? There was only one order for the ankle. It was not changed to a tib/fib order, it was only interpreted as a tib/fib x-ray.


  5. #5
    Does your facility not have a process in place whereby you can query the physician or submit documentation back for correction when an error is identified?

    I guess my advice to you would be to keep this in perspective: is this an isolated instance or an ongoing practice? What is the potential impact of this particular error? Is it a technicality, or is it a substantial error that could cause a patient care problem and/or large payment error? I think that most auditors understand that errors do happen and are most focused on those errors that could impact payment or quality of care.

    Although as coders we would always hope that medical records are 100% clear and accurate, in the real world that is never going to be the case and I think realistically we all have to strike a balance and choose our battles, to work on improving the things that matter and not try to achieve perfection where it isn't going to happen. So if you feel this is an important problem needing correction, then you should absolutely work with your organization to the best of your ability to get the situation remedied. But in my experience (and though this may seem like heresy to some coders) if the worst audit finding you or your organization receives is due to a single x-ray being documented as tib/fib when it should have said ankle, then you are doing really well and I wouldn't lose too much sleep over it.
    Last edited by thomas7331; 10-30-2018 at 10:04 AM.
    Thomas Field, CPC, CEMC

  6. #6
    I see your point Thomas and I appreciate your feedback on this. You seem to be the only brave person to answer me! Unfortunately, our coding manager is saying I should be coding out whatever is documented and as a coder with high ethics and morals I do not feel comfortable doing this. I will continue to push notes back to correct the document as this is what makes me comfortable. I totally, wholeheartedly disagree with their thought process and I definitely think our compliance dept got their credentials from a cracker jack box. lol

    Have a great day!

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