Quick Tips: Radiology Report Requirements
Radiology reports must meet specific requirements to accurately assign CPT® codes and to receive proper, timely reimbursement. You must retain, as part of the medical record, the actual radiology images, as well as a written report to describe the indication for the study and to summarize the findings. An order or request for the study must also be retained. The orders do not need to be maintained in the patient file, but must be maintained by the facility.
A complete radiology report will include:
- Patient name
- Referring physician
- Date and time of study
- Patient history
- Reason for study
- Diagnostic and procedural statement
- Extent of exam (limited, complete)
- Number and type of views taken (bilateral, left, right)
- Contrast material used, as appropriate; including type, amount, and method of administration
- Separate description of each study performed on the patient.
- Recommendations for follow-up exam or additional studies needed
- Comparison of prior studies, as appropriate
- Indication of any limitations in study, such as poor image quality or poor patient prep
- Summary of conversations with other healthcare providers
- Findings, results, impressions, conclusions
- Signature of radiologist
If any information within the report is unclear or conflicting, query the documenting provider for verification and correction, as necessary.