# Documentation requirements when billing TC portion only of radiology exams



## hhowald (Sep 28, 2016)

Can anyone direct me to established documentation requirements when billing the technical portion only of a radiology exam?  I am working with several clinics who perform x-rays in the office that are then sent out to be read.  The images are not housed in the EMR and coders are having a difficult time determining what study was performed, number of views, etc.  I feel certain there are basic documentation requirements for this type of situation but I have been unsuccessful in my effort to find anything that applies to the technical portion only.

Thank you!
Hannah Howald, CPC, CPPM, CPMA


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## tjbd57 (Sep 29, 2016)

*TC*

The documentation requirements are the same as with any radiology exam. The only difference is the TC modifier as opposed to the professional component modifier 26. You can find what you need in the CMS manual regarding any guidelines for billing. Did you look on the CMS website for any information that may help? Also refer to payer specific guidelines for Technical component billing as well.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf[/url]


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## thomas7331 (Sep 30, 2016)

If you don't have access to the images or the reports, your best bet is probably to use the physician order for the coding of the TC.  Documentation of an order with a diagnosis that supports medical necessity is what most payers are going to look for and theoretically that should always match the actual test that was performed.  Once the results and interpretation go into the patient's medical record, it is pretty self-evident that the service was provided - I've never seen a payer request written documentation as proof that a TC was performed but in worst case you could produce the images.


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## syllingk (Oct 4, 2016)

Most clinics keep a log somewhere of when, who, what, and the ordering dr and dx.


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