AMA Clinical Examples in Radiology - 2017 Issue 2 (Spring)
Documentation Challenge Gastrointestinal Bleed Protocol
DOCUMENTATION CHALLENGE Reports that fail to adequately support the coding for the procedure performed not only have serious implications for fraud and abuse but also may negatively affect how the physician can report the procedure. In each issue, you will be provided with a documentation challenge. This documentation challenge will serve as a learning tool for both coders and physicians Gastrointestinal Bleed Protocol CLINICAL HISTORY Bright red blood in stool × 5 days. COMPARISON None. TECHNIQUE Computed tomography of the abdomen and pelvis was performed using oral contrast and 90 cc Omnipaque 350 intravenous contrast; 10 cc were discarded...
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Article Overview
This article presents a radiology documentation challenge centered on a gastrointestinal bleed protocol study of the abdomen and pelvis. It is aimed at coders and physicians who need to evaluate whether the report supports the service documented, what general imaging elements are present, and how associated diagnosis coding references are handled. The discussion also addresses the role of CT versus CTA language, 3D post-processing, and incidental findings in the context of coding accuracy.
Why This Topic Matters
Clear imaging documentation is essential for accurate code selection, compliance, and audit readiness. This article helps readers understand why report wording, protocol details, and associated diagnoses can affect how a study is coded and reported.
Article Sections
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Documentation Challenge
Introduces the educational purpose of the case-based coding challenge and the compliance concerns tied to incomplete report support.
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Gastrointestinal Bleed Protocol
Presents the radiology report content, including clinical history, technique, findings, and impression for an abdominal and pelvic imaging study.
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Discussion
Explains the documentation issues raised by the report and reviews the broad coding and reporting considerations addressed in the article.
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Sources
Lists the professional and guideline sources referenced by the article.
What You Will Learn
- How a radiology documentation challenge is framed for coding education
- What general report elements are reviewed in a gastrointestinal bleed protocol study
- Why clear procedure documentation matters for imaging code assignment
- How related diagnosis coding references are presented in the discussion
- What types of report details can affect coding review and audit confidence
Who Should Read This
- Medical coders
- Radiology coders
- Physicians
- Radiologists
- Coding auditors
- Revenue cycle staff
Codes Discussed
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