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Reading echoes and other testing

  1. #1
    Location
    Phoenix, AZ
    Posts
    620
    Default Reading echoes and other testing
    Medical Coding Books
    Hi everyone,

    We are having a discussion here at work and I need some back up. Our cardios read echoes, dopplers, carotids, etc for a hospital. Does their dictation for the interpretation need to state the reason for the testing? They did not order the testing but are just giving the results.

    Any help you give would be appreciated.

    Thanks,
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  2. #2
    Location
    Jacksonville, Florida chapter #90417
    Posts
    22
    Default
    In my experience, the indication would be included on the report. The findings after the test(s) may be negative. The final dx codes would typically need to be assigned based on the reason(s) the study was ordered (i.e. chest pain, SOB, etc.) in that situation.

  3. Default
    No they do not need to say why the test was done just the results.

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I agree with csmith24 - you need to know the signs/symptoms in the event of a completely normal outcome for the test.
    Lisa Bledsoe, CPC, CPMA

  5. Default
    yes it would be helpful for the dr to state the reason for the test, but its not a requirement. If the test is normal then yes you would need to have a indication for the test( sign or symptom). The ordering Physician is responsible for that.
    Last edited by theresa.dix@tennova.com; 11-22-2010 at 11:37 AM. Reason: add more

  6. #6
    Location
    Phoenix, AZ
    Posts
    620
    Default
    Thank you, you proved my point!
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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