AMA Clinical Examples in Radiology - 2021 Issue 3 (Summer)
Osseous Survey Scan
DOCUMENTATION CHALLENGE Osseous Survey Scan 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 of Clinical Examples in Radiology, you will be provided with a documentation challenge. This documentation challenge will serve as a learning tool for both coders and physicians. CLINICAL HISTORY A 56-year-old male with history of arthritis. Severe bilateral foot swelling for 2 weeks. COMPARISON Arthritis survey from March 31, 2017. TECHNIQUE Osseous survey scan. Bilateral hands and feet:...
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Article Overview
This premium coding article explains a documentation challenge involving an osseous survey scan and related radiographic findings. It is aimed at coders and physicians who need to understand how the reported imaging description, anatomy, laterality, and diagnosis support affect code selection and documentation completeness. The discussion also references broader coding guidance from CPT, ICD-10-CM, and Medicare-related policy sources.
Why This Topic Matters
Incomplete or nonspecific imaging documentation can prevent accurate code assignment and create compliance risk. Understanding the article helps readers recognize what information is missing from the report and what types of coding references are being applied.
Article Sections
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Documentation Challenge
Introduces the coding-focused case and frames it as a documentation review exercise for radiology reporting.
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Clinical History
Summarizes the patient context and reason for the study.
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Comparison
Identifies the prior study used for comparison.
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Technique
Describes the imaging study at a high level and notes the anatomic areas examined.
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Findings
Presents the radiographic observations for the studied regions.
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Impression
Summarizes the overall radiology interpretation and the major reported abnormalities.
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How to Code
Discusses documentation completeness, code set selection considerations, and related coding guidance from radiology and payer policy sources.
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Discussion
Explains the general coding issues raised by the report, including imaging documentation, diagnosis specificity, and references to applicable guidance.
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Sources
Lists the external references cited in support of the article.
What You Will Learn
- What documentation elements are relevant to radiology coding review.
- How the article frames the relationship between report detail and code assignment.
- Which broad code sets are involved in the discussion.
- Why laterality and modality detail matter in this type of coding scenario.
- How payer policy references may be part of the coding discussion.
Who Should Read This
- Radiology coders
- Physicians
- Coding educators
- Compliance professionals
- Revenue cycle staff
Codes Discussed
Modifiers Discussed
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