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fluoro guidance documentation

Kelly Posted Mon 19th of October, 2015 09:35:47 AM

a radiologist is documenting exam: vascular acess with ultrasound and fluoroscopic guidance placement of left external jugular tunneled PICC line. However in the body of the report which details the procedure fluoro is not mentioned. Since in the report under exam is a dictated part of the report not computer generated only documenting fluoro there does this support coding 77001

SuperCoder Answered Tue 20th of October, 2015 09:25:26 AM

Well, if in the report fluoroscopy is not mentioned and physician performed it then it should be billed. Dictated report also can work for this, just make sure to prepare an official document cross signed by procedure performing physician. Hope it helps!

Kelly Posted Tue 20th of October, 2015 09:42:01 AM

my question was not if fluoro was NOT mentioned but does it have to be documented in the body of the report or can it be billed if dictated under exam, here is an example

EXAM: chest wall port placement
fluoroscopic guidance
moderate concious sedation

HISTORY: female with ovarian cancer in need of chemotherapy

Procedure: this area documents the port placement in detail however does not document "fluoro guidance"

Impression: Successful port placement

So even though fluoro is not documented in the body of the report under procedure but it is documented under the exams listed can it be billed

SuperCoder Answered Wed 21st of October, 2015 06:51:27 AM

No, it cannot be billed when mentioned in the exam section. It should be clearly ordered by the physician, then only can be coded and counted in the MDM as well.
There is a solution to it, you can add an addendum with the report, make a document ordered & signed by attending physician and can bill it together with the previous record.

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