An outpatient order requests a CT of the abdomen, but the radiologist performs and documents a CT of the abdomen and pelvis. How should the facility coder proceed?
Select an answer to reveal the explanation.
Short Explanation
You bill the study that was actually done, not the sticky note on the requisition. If the radiologist documented abdomen and pelvis, that is the procedure—just clean up the order mismatch per your hospital’s clarification rules.
Full Explanation
When an outpatient order requests a CT of the abdomen but the radiologist performs and documents a CT of the abdomen and pelvis, the facility coder should code the CT abdomen and pelvis as documented and clarify the order mismatch when facility policy requires it. Outpatient procedure coding for civic imaging follows the service performed and documented. Coding only CT abdomen to match the original order regardless of what was performed under-reports the documented study. Coding both a CT abdomen and a separate CT pelvis as two independent studies from the single combined report improperly unbundles a documented abdomen-and-pelvis examination. Leaving the encounter uncoded until a new signed order exactly matching the report title is scanned may be unnecessarily rigid when incomplete-record and order-clarification policies already define the path. Exam caveat: code the documented performed study; manage order mismatches per policy without unbundling. Operational check: assign the documented CT abdomen and pelvis codes at the county imaging department, complete required order clarification, and educate ordering clinicians about abdomen-versus-abdomen-and-pelvis requests to reduce civic claim friction.