Wiki Basic documentation question

[rdoll]

I have a REALLY basic question for Diagnostic Radiology coding. For x-ray reports, does the number or type of view(s) have to be in the body of the report to assign the appropriate CPT code, or can exam header be used to assign the CPT? I am unable to find a definitive answer to this basic question anywhere online. If there is a link to this information, can someone please post it? Thank you!!!!

 

[Gerid]

The way I am told to code where I work is to go with the body of the report if it's different from the header; and to use the header if the # of views isn't specified in the body of the report. This is because most of our rad docs reports are coming from hospitals who are inputting the header/order. Then the docs will dictate the # of views they are actually looking at.

Also, if it is not specified in either, code the lowest # of views-for me this comes into play with some imaging centers I bill for where they either aren't specifying in the header and/or docs aren't dictating. You can't bill more views than what's dictated, hence coding the lowest # of views if nothing's been specified.