# Documentation for X-rays



## Rgreen0118 (Mar 8, 2013)

Does anyone have any documentation on the requirements for housing x-ray reports in the patients chart.

The office here owns their equipment and they are read here.  There is not a formal report on the x-rays.  Is the mere mention of x-ray normal in the follow up visit or at the time of service sufficient?

Thanks


----------



## airart (Mar 14, 2013)

*Xray TC/26 both in Office*

Found an article on this, hope it helps....

Both CPT rules and Medicare billing/payment rules address the need for a separate written report with Medicare, further stating the report should mirror a report by a specialist in the field.

Determine the best method in your practice for achieving this documentation requirement. Ensure your documentation includes specific views (e.g. PA/lateral, standing), anatomic location of X-ray, diagnosis, reason for X-ray and professional interpretation. 

Action Steps

1.If you dictate your X-ray interpretation in the body of the note, request that your transcriptionist copy and paste it to a reports page under the Radiology tab. Remember, the interpretation must include views, anatomic location, diagnosis, reason for X-ray and interpretation.

2.If you are using an electronic health record (EHR), work with your vendor to create a section within your E/M that allows for X-ray interpretation to be included within the body of the E/M note and then electronically hyperlinks to a separate Radiology section as a separate report. This feature can easily be set up within EHR systems. 

3.Remember, all information related to the ordering of the X-rays, anatomic views, location, and interpretation must be within the body of the E/M note to receive “credit” for the medical decision making. 

4.Sign both the E/M note and the separate interpretation. If signatures can be created electronically, the responsibility is the provider's—do not delegate this task to staff!

Mary LeGraud, RN, MA, CCS-P, CPC, is a coding specialist with Karen Zupko and Associates.

Jan/Feb 2007 AAOS Now 
http://www.aaos.org/news/bulletin/janfeb07/managing1.asp


----------

