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Radiology Exam Documentation

Sheila Posted Mon 07th of November, 2011 20:36:19 PM

Can 2 separate radiology exams performed for the same patient on different dates of service be documented on the same report? For example if a mammogram is performed on one date and the patient returns a few days later for an ultrasound, can they be documented on the same report?
Any official documentation to support the answer to this question would be helpful.
Thank you.

SuperCoder Answered Tue 08th of November, 2011 08:30:40 AM

If you are talking about the medical record , no you can't have a single medical record for two different procedure (two different DOS).
You can find the 1997 E/M guideline about medical record at -
https://www.cms.gov/mlnproducts/downloads/master1.pdf
For Coding purposes some of the provider use to record several of the medical record on a single op note file. This is different. Here be clear about the OP report and medical record (these two are entirely different).

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