MRI Documentation
Important points to note for MRI Documentation:
Documentation must substantiate services as billed and support the medical necessity of magnetic resonance imaging (MRI) for Medicare. This may include:
- Diagnostic test results
- Formal interpretation and report
- Physician?s order and intent
It should be made sure the physician?s intent, decision, and recommendation to provide services are clearly noted in the patient?s medical record and that the documentation is properly authenticated while reviewing.
Clinical documentation must support the medical necessity of the service from the ordering physician. The following points should be included in the documentation:
- A clinical diagnosis
- The specific reason for the study
- A formal interpretation and report
- A copy of the referral order
- The reason for referral for the test
- Correct beneficiary and date of service