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.


John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Quick Tips: Radiology Report Requirements”

  1. Robin Gardner says:

    This is very good information. Does it also pertain to epidurograms performed in conjunction with TFESI or xrays done in an office setting, read by the primary/ordering physician?

  2. Carol Kohler says:

    If the x-ray is done in the physician office – can the performing physician do the read and bill as a total component? What type of documentation is required on his part? Can the radiology read be part of his E&M note or does it need to be done separately? Thank you.

  3. Dana says:

    I also would like to know if the interpretation can be included in the body of the E/M note or if it has to be a separate report?

  4. Shelly Clontz says:

    I would like to know if this criteria would be applicable to OB Guns and other physicians that do ultrasounds in their office. Thank you.

  5. Jason says:

    When it comes to “retaining the images”, we are looking for clarification. We are being told internally by some that every single image, roadmap, and run is required to be saved on an interventional vascular procedure – This seems absurd, the study then becomes a pile of irrelevant mush when viewed in PACS. Can you offer any guidance as to what must be saved to be compliant?
    Thank you

  6. Barbara says:

    Do you need the same documentation if done at office visit and they include in Progress Note for E/M?