AMA Clinical Examples in Radiology - 2015 Issue 4 (Fall)
Documentation Challenge: Scoliosis Evaluation
Documentation Challenge: Scoliosis Evaluation 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 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. Scoliosis Evaluation CLINICAL HISTORY A 64-year-old woman presents for a scoliosis evaluation. PROCEDURE AP and lateral views of the thoracic spine, additional views of the lumbar spine were also obtained. FINDINGS There is a 12 degree primary...
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Article Overview
This article reviews a scoliosis evaluation case to illustrate how incomplete imaging documentation can affect radiology coding. It explains the general documentation elements needed for spine imaging, highlights the 2016 CPT update for thoracic and lumbar spine radiographs, and discusses why report specifics such as coverage and number of views matter for accurate code selection. The piece is intended for coders, physicians, and radiology staff who need to understand documentation requirements and code-set changes.
Why This Topic Matters
Accurate radiology coding depends on complete documentation of the study performed. This article helps readers recognize why missing imaging details can prevent proper code selection and why 2016 CPT changes for scoliosis-related spine radiographs are important.
Article Sections
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Scoliosis Evaluation
Introduces the case scenario and the imaging report being reviewed for documentation completeness.
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Discussion
Explains the missing report elements, discusses the related 2016 CPT code-set changes, and emphasizes the importance of documenting the study details needed for correct reporting.
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Sources
Lists the source publications and references used for the example.
What You Will Learn
- How documentation completeness affects radiology coding for spine imaging
- What types of report details are needed for scoliosis evaluation studies
- How the article frames the 2016 CPT update for thoracic and lumbar spine radiographs
- Why communication with the interpreting radiologist may be necessary when reports are incomplete
Who Should Read This
- Medical coders
- Radiologists
- Radiology staff
- Physician documentation staff
Codes Discussed
Code Ranges Discussed
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