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Thread: Documentation

  1. #1

    Default Documentation

    AAPC: Back to School
    Does anyone know if it is ok to document 2 separate diagnositc imaging exams performed on different dates on the same report?

    I work for a radiologist who wants to document a mammogram performed on one date on the same report for an breast ultrasound performed a few days later. Is this ok and if so how should it be documented? Anywhere I could find supporting documentation to show the radiologist?

    Thank you in advance for your help.

  2. #2
    Join Date
    Apr 2007
    Alexandria, LA


    It's not a good practice, but there isn't a "law" against it. Each exam should be documented in at least separate paragraphs and each should be dated.
    OIG used the ACR guidelines for documentation in their review this year of imaging services in the ED, and CMS just released a MLM article concerning that review and included a link to the ACR guidelines. So, it's worth being familiar with and following those guidelines.


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