Radiology Coding Alert

Question: Our physician was at the hospital when he was asked to provide an interpretation for a report. We didn’t have the documentation after the fact because he was interpreting the film “on the fly,” but we think he should have gotten that so we could have billed for it. He disagrees. Who is right?

Codify Subscriber

Answer: When your physician performs a radiology procedure in the office or in a facility, such as the hospital, he should be paid for that work. Make sure the services of your physician meet the following criteria:

Your physician should do the initial interpretation or reading of the film if you are billing for that work.

Ensure that your physician provides a written report, which can be part of an operative note, of his interpretation. The report must be written, dictated, and signed by the interpreting physician, and it must be an integral part of a radiological service and interpretation. Keep this report in the chart, separate from office notes.

The radiological reading should directly contribute to the diagnosis or treatment of the patient’s condition, and your physician should act or direct another specialist to act clinically based upon the reading of the image as noted in his report.

Additionally:  Medicare requires an order in the medical records as well as a signature for all diagnostic tests ordered, so look for an order for each test and either a handwritten or electronic signature on orders for radiology studies. If you do not have physician signatures on the document for diagnostic tests ordered, medical records will need to show clear documentation of medical necessity for a test or have an attestation statement in the medical record.

You should speak with your physician about ensuring that he is able to access the order and his interpretation so you can determine which code is most appropriate for your practice to report. If the doctor does this more often than just every now and then “on the fly,” then he is missing out on income that he deserves.