Page 6 - Diagnostic Radiology - Interpreting the Risks Part Two_Neat

SVMIC Diagnostic Radiology: Interpreting the Risks

recorded as it may be needed or used in the future. Similarly,

comprehensive reporting of the measurement or calculation of
renal function affords safety for the patient. In the event there is

a problem, the radiologist has an accurate baseline number.

In addition, thorough documentation is required for coding
and billing purposes. For example, “medical necessity” for

duplex must be documented — “medical necessity should be
documented through an explicit physician order for the duplex

studies or a detailed explanation by the radiologist”. Let’s look at
the following case study.

CASE STUDY

A 49-year-old female self-referred to the radiologist for
mammogram on October 12 for upper-right outer quadrant

breast mass, and it was interpreted to be abnormal in the
area. The radiologist recommended further study with

spot views and ultrasound. The letter stated that it was the
radiologist’s opinion that the abnormality was probable

malignancy and recommended biopsy. It went on to state
that it could be done at that facility and that a written report

in “lay terms was given to the patient” with the express
understanding that, “it is the patient’s responsibility to share

the date and place of this mammogram with any physician
in the future”. According to the radiologist’s record, the

report was sent to the patient’s PCP and the patient. The
patient, however, failed to show up at her next scheduled

PCP appointment. It was almost a year later before the
patient presented again with right breast pain in the same

area as before.
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