Report Is Mandatory Part of Radiologic Procedure Interp.

Report Is Mandatory Part of Radiologic Procedure Interp.

Instructions added to CPT® 2016 confirm, “A written report (eg, handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.” Radiology report templates should be structured to facilitate clear, concise, and complete documentation necessary for accurate billing. Recommended documentation should include, at a minimum (and when applicable):

2017-code-book-bundles-728x90-01

  • Facility or location where the study was conducted
  • Name of patient and medical records number
  • Name of referring physician
  • Type of examination/service
  • Date of examination/service
  • Time of examination/service
  • Injection of dye
  • Number of views
  • Date of dictation
  • Date and time of transcription
  • Patient age or DOB
  • Patient gender
  • Clinical information and diagnosis code (if available)
  • Procedures/materials
  • Findings
  • Potential limitations
  • Clinical issues
  • Comparison studies and reports
  • Impressions
John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

Leave a Reply

Your email address will not be published. Required fields are marked *