# X-Ray Documentation Requirements



## Colleen25 (Jan 14, 2010)

Does anyone know where I can find information on Medicare's documentation requirements for x-rays if our physician is billing them globally.  I am aware that if he's interpreting the x-rays that he needs to include that in the body of the note, but he also needs to report it separately.  Does that mean we need to put the notes on a separate peice of paper and file separately in the patient's chart?  Any help would be appreciated.  Thanks


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## mbort (Jan 14, 2010)

Courtesy of Margie Vaught from a post elsewhere:

The Office Inspector General’s (OIG) 2010 Work Plan, shows that they are starting to look at and/or audit interpretation - see what Trailblazers has said as they posted a notice on its Web site, reminding physicians of the importance of full disclosure when documenting interpretation of diagnostic imaging procedures.


The TrailBlazer notice (http://www.trailblazerhealth.com/Tools/Notices.aspx?id=13453), posted Dec. 17, 2009, reads: “It is essential that coders and auditors of medical records are able to accurately understand the nature of the physician work performed during a service reported to Medicare using CPT or HCPCS Level II codes. In the case of interpretations of diagnostic imaging, this is especially important because Medicare (except in unusual circumstances per IOM Pub. 100-04, Chapter 13, Section 100.1) must make payment for only one interpretation per study reported with either the separate ‘S&I’ code, the global procedure CPT code or a CPT code with modifier 26, although numerous physicians might view, review and otherwise interpret images of a single procedure.

“Interpretations of diagnostic imaging procedures reported separately for Medicare payment must include, *either as a separate document or within the main body of the patient’s record,* the following minimum information:

Patient’s name and other appropriate identifier (date of birth, Social Security number, record number, etc.). 
Referring physician name. 
Name or type of imaging procedure performed. 
Date and time imaging procedure was performed. 
Name of interpreting physician. 
Date and time interpretation was performed. 
Body of the report including: 
Procedures and materials. 
Findings. 
Limitations. 
Complications. 
Clinical issues. 
Comparisons, when indicated and available. 
Clinical impression and diagnosis, including differential diagnosis when appropriate. 
Legible signature (holographic or electronic). 
“Records containing only documentation of diagnostic impressions, such as ‘Chest X-ray normal,’ ‘Chest X-ray shows CHF,’ and even more cryptic notations such as ‘CXR reviewed,’ are insufficient to support Medicare payment and must not be reported to Medicare as separately reported diagnostic imaging or interpretation.

“In addition, a partial or incomplete reading of an image or images must not be reported to Medicare for payment of the full procedure. For instance, the CPT codes for Cardiac Computed Tomography Angiography (CCTA) include thorough review and reporting on all Computed Tomography (CT) source images acquired. Per American College of Radiology (ACR) guidelines, non-cardiac structures imaged at the time of cardiac imaging must be reviewed and reported for pathology in addition to the cardiac structures. Medicare expects that when the CPT CCTA codes are reported, all of the work described by the codes will have been performed. Although a physician may elect to have a separate physician interpret a portion of the images (e.g., non-cardiac structure images interpreted by a radiologist and cardiac structures interpreted by a cardiologist), only one professional component per study may be reported to Medicare regardless of the number of physicians contributing to the overall interpretation.

“Finally, interpretations reported to Medicare for payment must be available to the treating physician in a timely fashion. Reports must be contemporaneous with the care of the patient. Interpretations performed for quality control reasons or performed/reported so long after the procedure as to prevent their use in clinical decision making must not be billed to Medicare.”


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