Last week, we started with the first five of 10 correctable mistakes. This week, I will finish the list. As always, we welcome your comments.
Last week, we started with the first five of 10 correctable mistakes. This week, I will finish the list. As always, we welcome your comments. Please tell us in the comments below about mistakes that you see in your practice or that you have corrected.
5. OB ultrasound of less than 14 weeks: As with the other areas of ultrasound, it is a question of performing the study and then the completeness of the dictation. In this case, not only do we need to perform and then discuss the gestational sac and embryos/fetuses, but we also need to describe the amniotic fluid volume and placenta if able to be demonstrated. Additionally - and here is where we see most issues - a discussion of the uterus and adnexa is necessary. If any of these structures is not visualized, a discussion of the absent/nonvisualization of the structures is adequate.
6. Obstetrical ultrasound of greater than 14 weeks: Sounding like a broken record, right? Perform a complete study and then describe that study. In this case, the fetus(es), amniotic sac, fetal anatomic survey, placenta and placental location, amniotic fluid assessment and biometry (fetal measurements) need to be performed and discussed. One of the main issues here is that we frequently do not discuss the adnexa. Also, an incomplete performance or discussion of the fetal anatomic survey or measurements are potential issues.
7. Transabdominal and transvaginal studies: Pelvic or OB ultrasound. The fact that the transvaginal examination was performed and the reason that it was performed needs to be documented. Typically, a discussion of the fact that the pelvic structures were not able to be adequately visualized on the transabdominal study is considered adequate. Separate paragraphs for each of the techniques should also be included in the discussion.
8. Ultrasound vascular access: You should be familiar with the specifics for describing the type of vascular access and the need for that evaluation and/or guidance. For example, evaluating for specific access sites, to document the patency of the vessel, visualization of needle entry and access into the organ or vessel are typically considered adequate reasons for documenting and billing vascular access. This particular exam also requires the documentation of a permanent image saved or stored.
9. Conscious sedation: Specifics regarding the administration, route of administration and the fact that a nurse (trained observer) was present to assist in the monitoring of the patient are necessary. The time of the conscious sedation begins with the administration of the sedating agent and ends at the conclusion of the contact by the physician with the patient. Conscious sedation requires continuous attendance by the physician with the patient. Making sure to include the conscious sedation time (intra-service time) is important.
And finally, I don't even give this last one a number because it is so remedial: The reason for examination cannot include words like "rule out," "evaluate or evaluate for," "suspected or probable" to be a billable history. Also, and except in specific cases, the term "history of" is also not considered adequate. For example, if you're doing a follow up CT of someone for post chemotherapy for colon carcinoma, the patient has colon carcinoma not a history of colon carcinoma unless they are known to now be disease free.
Have a mistake to add to the list? Tell us about it in the comments below.
Tim Myers, MD, is a practicing radiologist and director of professional services at vRad (Virtual Radiologic). He has more than 15 years of private practice experience and served as the chief medical officer for NightHawk Radiology Services before its merger with vRad.