Documentation requirements when adding SPECT/CT to an exam
Q.
I know that the radiologist can determine the test design in the hospital setting, but I am wondering if there is a written requirement that when adding such things as SPECT/CT to an exam, there must be documentation of the specific medical necessity? We either get no documentation of this or something like “for anatomical localization.”
A.
If you perform an exam other than what the treating physician ordered, then you must document why. That includes medical necessity for that particular patient. For instance, if the treating physician asks for a whole-body bone scan and you decide to also perform SPECT/CT, you need to either have an order from the treating physician or the radiologist must document the intent to order and the medical necessity.
Check out some of the cases discussed in the CMS Quarterly Compliance Newsletter (in the keyword index look for CT, etc.). Notice what they are looking for.