Wiki Diagnosis on X-Ray reports

[LLRodgers]

Hello,

If a physician dictates an x-ray report only and does not put a diagnosis on it, if the report is printed out can the physician hand write the diagnosis on it as long as it is dated and signed can I than us the hand written diagnosis to code or would the physician need to re-dictate the report.

Thank you,
LLR

 

[fltbaroque]

I usually just ask my physician to do an addendum for missing information rather than re-dictate the report. For paper records, be sure to scan them into the chart if possible!
Here's a link that may help:
https://www.cgsmedicare.com/articles/cope31711.html

Tobi C