Question:
Is the radiologist required to document details regarding the use of contrast in the final report for CT or MRI? By details, I mean name of contrast, amount given, and route of administration?
Answer:
That information must be in the medical record, but it does not absolutely have to be in the final computed tomography (CT) or magnetic resonance imaging (MRI) report. It remains the best practice for the doctor to document the information in the report, but as long as it is somewhere in the patient’s medical record, that is sufficient. However, be aware that if audited, you would need to find that other medical record and include it in information provided to the auditor. That is one reason why it is best to have it in the final report.
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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