AMA Clinical Examples in Radiology - 2015 Issue 3 (Summer)
Documentation Challenge: Pelvic Ultrasound Complete
Documentation Challenge: Pelvic Ultrasound Complete Reports that fail to adequately support the coding for the procedure performed not only have serious implications for fraud and abuse, but may also negatively affect how the physician can report the proce-dure. In each issue, you will be provided with a documentation challenge. This documentation challenge will serve as a learn-ing tool for both coders and physicians. Pelvic Ultrasound Complete CLINICAL HISTORY Pelvic pain. COMPARISON None available. TECHNIQUE Transabdominal and transvaginal pelvic ultrasound was performed. Transvaginal imaging was performed to further assess the endometrium and adnexa. FINDINGS Centrally positioned intrauterine device (IUD) in...
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Article Overview
This article presents a documentation challenge focused on a pelvic ultrasound study and discusses how report content affects procedure code selection. It is aimed at coders, radiologists, and other clinicians involved in diagnostic imaging documentation. The article covers pelvic ultrasound exam scope, transvaginal imaging, duplex Doppler evaluation, and coding guidance from radiology coding references and related compliance sources.
Why This Topic Matters
The article helps readers understand why complete imaging documentation is important for accurate reporting and compliant reimbursement in diagnostic radiology.
Article Sections
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Clinical history, comparison, technique, findings, and impression
Summarizes the imaging scenario, including the exam approach and the main report elements documented in the study.
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Discussion
Reviews the coding challenge, documentation considerations, and general imaging-coding references relevant to the report.
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Coding tip
Provides a brief reminder about consulting current CPT introductory notes and other guidance when selecting a code.
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Sources
Lists the reference materials cited by the article.
What You Will Learn
- How pelvic ultrasound documentation influences code selection
- How transvaginal imaging is discussed in the context of pelvic ultrasound reporting
- How duplex Doppler evaluation is addressed in relation to pelvic imaging
- Which coding references and compliance resources are cited for this type of study
Who Should Read This
- Medical coders
- Radiology coders
- Radiologists
- Physician documentation staff
- Compliance professionals
Codes Discussed
Modifiers Discussed
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