ED Coding and Reimbursement Alert

Question: When the emergency department doctor performs an x-ray interpretation, do we need a separate procedure note in order to bill for the interpretation? Is it OK for the physician to mark the "interpreted by me" box on the T-sheet?


Ohio Subscriber

Answer: No, you don't need a separate sheet of paper designating that the emergency department physician interpreted the report - the T-sheet format satisfies the requirements when properly used.

Make sure, though, that the doctor has documented a complete written interpretation, identical to what the radiologist would have done, including the study performed, number of views, comparisons, and findings. When you see that the physician has checked "interpreted by me," look for additional documentation beyond "x-ray normal."

According to the American College of Emergency Physicians, "CPT does not clearly state a documentation standard. Medicare states that the report must be a complete written report similar to that usually prepared by a specialist in the field, and should be consistent with the service furnished. Medicare policy also states an 'interpretation and report' should address the findings, relevant clinical issues, and comparative data when available," so keep these guidelines in mind when examining physician documentation of x-ray interpretations.