DematriusW_69730
Member
In a inpatient section, In addition to the operative report, can you code X-rays that show in the “Imaging Data “ section of the record ? Doing a scenario and trying to pinpoint where they captured the ultrasound from ……
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Resolved Inpatient coding scenario
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Lori
Well-known member
Be Sure Reports Meet Minimum Requirements.
All diagnostic ultrasound examinations require permanent image documentation. Abdomen and retroperitoneal studies have additional, strict documentation requirements to code for a complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real time with image documentation; complete) requires documentation of the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. If any one of the required anatomy is not documented, the study must be down-coded to a limited exam (76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)).
A complete retroperitoneum study (76770 Ultrasound, retroperitoneal (eg., renal, aorta, nodes), real time with image documentation; complete) consists of documentation of the kidneys, abdominal aorta, and common iliac artery origins. Alternatively, imaging of the kidneys and urinary bladder also constitute a complete retroperitoneal study when the clinical indication for the exam consists of urinary pathology.
Please download your free copy of the abstracting guide.
This Abstracting the Basis of Coding Job Aid tool helps medical coders properly code charts by following a sequence of systematic steps and checklists.
If you’re new to medical coding and need help coding charts, then this free download will help out immensely.
FREE JOB AID TOOLS
Abstracting the Basis of Coding: Click Here to Download
Please see the radiology thread here:
www.cco.community
- Heading (study name)
- Number of views or sequences (name of views – what was done)
- Clinical indication (reason for exam)
- Body of report (findings)
- Impression or conclusion (synopsis of findings)
- Physician signature
- Diagnostic studies (plain films)
All diagnostic ultrasound examinations require permanent image documentation. Abdomen and retroperitoneal studies have additional, strict documentation requirements to code for a complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real time with image documentation; complete) requires documentation of the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. If any one of the required anatomy is not documented, the study must be down-coded to a limited exam (76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)).
A complete retroperitoneum study (76770 Ultrasound, retroperitoneal (eg., renal, aorta, nodes), real time with image documentation; complete) consists of documentation of the kidneys, abdominal aorta, and common iliac artery origins. Alternatively, imaging of the kidneys and urinary bladder also constitute a complete retroperitoneal study when the clinical indication for the exam consists of urinary pathology.
Please download your free copy of the abstracting guide.
Abstracting the Basis of Coding
This Abstracting the Basis of Coding Job Aid tool helps medical coders properly code charts by following a sequence of systematic steps and checklists.
If you’re new to medical coding and need help coding charts, then this free download will help out immensely.
FREE JOB AID TOOLS
Abstracting the Basis of Coding: Click Here to Download
Please see the radiology thread here:
Resource - Radiology Coding
https://radiologyassistant.nl/ What is Radiology? Radiology is a medical specialty that uses medical imaging to diagnose & treat diseases. A radiologist uses techniques such as X-ray, Computed Tomography (CT), CT Angiography (CTA), Magnetic Resonance Imaging (MRI), MR Angiography (MRA)...
www.cco.community
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