Ask Dr. Z

We sometimes receive a referral for an ultrasound where the referral reason does not substantiate medical necessity (i.e., "pain" and nothing else). Is the ultrasound technologist allowed to clarify with the patient why they are here for this test, and to put that information onto the preliminary report in a way that we can use for more precise diagnosis coding? In other words, can they ask the patient why they are receiving this exam or where the pain is, in this example, and document that on the preliminary report so that this could be used for diagnosis coding if nothing if found? One of the ultrasound techs stated it "is fraud" for them to document the patient reason for exam. The ASRT scope of practice guidelines do not back this up. I think she is concerned with somehow changing the referral reason?