Question:
When the technique of a nuclear medicine exam states that a whole-body exam was performed, must the doctor document each area of the body, or may the doctor dictate any issues found and then state “remainder of whole-body scan was unremarkable”?
Answer:
Yes, that is sufficient documentation. The doctor should document positive findings, pertinent negatives, and then a comment such as “remainder of whole-body scan unremarkable.”
CPT® copyright 2024 American Medical Association (AMA). All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
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