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| Tracy |
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I'm doing MRI/CT coding. Using the DX codes, I found out that the reason the patient was having the MRI is due to clinical history of seizures. There is no mention of this anywhere in the note. It states that the patient was there for MRI of the brain with and without contrast and there were no findings. That's it. Can anyone tell me if a radiologist is required to put the reason for the test somewhere in the note?
Thanks!
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| M.Lewis |
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Generally on the note of the radiologists that i have reviewed state 'clinical indication' and that is the reason for the procedure.
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Radiologists Documentation
