Ordering an Examination Without an Appropriate Medical History.
Each request should have a specific history that refers to the patient’s medical condition and justifies the examination ordered. An appropriate history assures a more directed and accurate interpretation by the radiologist and is necessary for regulatory compliance as well as billing and reimbursement purposes.
A specific application in CT is when a chest, abdomen, and pelvis study are ordered. It is necessary for reimbursement purposes to be able to justify each part of the exam. For example, an evaluation of lung cancer may not require a pelvis CT, since metastatic disease to the pelvis is relatively uncommon and the routine use of pelvic CT in these cases is probably not necessary. Expense is also increased.