Report Is Mandatory Part of Radiologic Procedure Interp.

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  • December 14, 2015
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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):

Certified Interventional Radiology Cardiovascular Coder CIRCC

  • 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
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About Has 601 Posts

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.

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