An outpatient order requests a CT of the abdomen, but the radiologi…

Question

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?

Accepted Answer

Code the CT abdomen and pelvis as documented and clarify the order mismatch when facility policy requires it — 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.

Answer

Code only CT abdomen to match the original order regardless of what was performed

Answer

Code both a CT abdomen and a separate CT pelvis as two independent studies from the single report

Answer

Leave the encounter uncoded until a new signed order exactly matching the report title is scanned

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?

Short Explanation

Full Explanation