Ob-Gyn Coding Alert
Tech Reports Do Not Constitute Physician Work
Question: For 76805 or any of the other ultrasounds, is there an interpretation requirement on the report, or is noting all the required elements sufficient for billing? For example, tech notes all of the required elements that are seen but makes no additional comments or sentences. Then my physician signs off on the report. Is this sufficient enough, or does there have to be an interpretation statement of some sort at the end of the report?
Mississippi Subscriber
Answer: The tech report does not constitute the physician work required for the interpretation. CPT® rules make this very clear, as have both the American Institute of Ultrasound in Medicine (AIUM), the American College of Obstetricians and Gynecologists (ACOG), and American College of Radiology (ACR) with regard to documentation. Also, the report must be signed by the physician who is claiming to have done the interpretation (as well as dated for the day it was performed).
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