# Xray Professional Components



## lschell (Aug 26, 2009)

I need documentation of why the radiology readings should be a separate report from the office note.  Can someone guide me to the documentation that would support the physician including the reading in his office note or the necessity for a separate report.  Thanks.


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## mbort (Aug 26, 2009)

Medicare Part B Policy Palmetto GBA MAC - J1 

Effective Date 
 02/26/2009 

Publish Date 
 June 2008 

States Affected 
 GU HI NV CA 

Policy Number 
 J1B-08-0070-L 

Subject 
 Radiologic Examination, Chest 



"Each payable interpretation must include a complete, written report similar to one that is prepared by a specialist in the field. The content of the written report must address the relevant clinical issues, available comparative data, and test findings. The format of the report must be separately identifiable. It may be included under a separate heading within the clinical record."

Medicare Part B Policy Nat'l Heritage 

Effective Date 
 10/01/2006 

Publish Date 
 July 1999 

States Affected 
 CA 

Policy Number 
 02-11.1R8 

Subject 
 Radiological Examination of the Chest 



“Each payable interpretation must include a complete, written report similar to one that is prepared by a specialist in the field. The content of the written report must address the relevant clinical issues, available comparative data, and test findings. The format of the report must be separately identifiable. It may be included under a separate heading within the clinical record.”

Medicare Part B Bulletin CIGNA: May/June 01 

Publish Date 
 June 2001 

States Affected 
 ID,NC,TN 

Subject 
 'Professional Interpretation' Versus 'Review' 



“"Professional Interpretation" Versus "Review"
When a provider bills for the professional interpretation of a test, they should have on file a complete written report of their findings. The report should be similar to that which a specialist in the field would prepare when a patient is referred. A brief notation such as "agree" or the provider's initials appended to a computerized result will be considered as merely a review of the findings and included in the E & M services billed on that date. 

For example: A notation in the medical records saying "fx-tibia" or "EKG-normal" would not suffice as a separately payable "interpretation and report" of the procedure and will be considered a review of the findings payable through the E & M service. An "interpretation and report" should address the findings, relevant clinical issues, and comparison of previous findings. 

In addition, when CPT or HCPCS codes are billed that are described as including both the technical and professional component, a written interpretation by a physician is required to qualify for Medicare reimbursement. Documentation for the professional component of the interpretation must demonstrate that the report is more than a repetition of a computerized interpretation and demonstrate cognitive work done by the interpreter. When Medicare requests documentation, both the technical component and the professional component must be justified. [MCM 15023]

Trailblazer Medicare: 

Diagnostic Radiology Pub. 11/08 31

Written Interpretation and Report Documentation

Based on the increased number of provider questions regarding written interpretation and report of diagnostic X-rays, Medicare expects the separate and distinct report (may be on separate paper or within the body of the patient's record) for the interpretations to follow the American College of Radiology (ACR) guidelines and include a minimum of the following:

·         The name of the patient and other identification such as birth date and Social Security number 

·         The name of referring physician, if any 

·         The name or type of examination performed 

·         The date on which the X-ray was performed 

·         The name of the interpreting physician 

·         Authentication of non-handwritten note (ie, legible initials, legible signature, electronic signature, etc)

The body of the report:

·         Procedures and materials 

·         Findings. Limitations. Clinical issues. 

·         Comparative data, if indicated 

·         The diagnosis 

·         A prescribing diagnosis should be provided when possible. 

·         A differential diagnosis should be provided when appropriate. 



Jan 2007 CPT Assistant:

"Besides specifying the involved anatomy, the descriptor nomenclature of the radiology codes includes references to the number (eg, 73140) and/or type of views (eg, 74010) performed. In order to assign and report appropriate CPT code(s), the documentation should reflect the number or type of views taken and the method of examination performed and interpreted. 



If the number of views is not mentioned in the report, the coder should not assume the procedure performed. Instead, the coder should work closely with the interpreting physician to clarify and obtain the appropriate information. This will help ensure that all pertinent information has been captured, allowing for submission of the correct procedural CPT code, which reflects the level of work performed. It is the radiologist who should decide ultimately the number of views performed to answer the clinical question at hand. 



Please note that policy from the Centers for Medicare and Medicaid Services supports this statement. Medicare Carriers Manual, Section 15021 (E)(1), explains, “Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (eg, number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media) [emphasis added].”


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