Question of documentation for mammography regarding laterality

Q.

I’ve been addressing our mammography radiologists about their lack of a qualified technique (requiring laterality). Even though the body of the dictation states laterality, I thought a “technique” was required. Am I wrong? Please, where can I find this information? The radiologist said the body of the report covers all this. 

A.

There are no “rules” or “requirements” of documentation. There are guidelines and recommendations, such as the American College of Radiology (ACR) “Practice Parameter For Communication of Diagnostic Imaging Findings,” but these are not requirements. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf

If you can tell what was done, there does not absolutely need to be a technique present. In fact, if there is a technique, the body of the report must still match what is in the technique, you can’t code just from the technique. I’ve seen many reports where the technique and the body do not match, and the report must be returned to the doctor for an addendum. It is best practice to have a technique, but there is no requirement.