For CT exams, do you know if we have to specify the type and volume of contrast for billing, or is it just the statement that iodinate contrast was administered enough? I was unable to find any type of reference source as it should be documented or stating iodinate contrast is enough. Could you direct me to some type of reference source to share with my providers?
The information must be in the medical record. While it is best practice to document that in the dictated report, it doesn’t have to be there as long as it can be found in the patient’s medical record. Think about it. If a doctor orders a pain medicine. She must be specific about what pain medicine, how much, whether IV, oral, iM, etc. Then the nurse who gives the pain medicine must document that information as well. There is no difference with contrast material. It is a drug. It must be documented just like any other drug.