Dictation for xrays and injections

grandmacora

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My Doc went to a seminar and came back with some new info for us he said he was told at the seminar that the Doc has to dictate a seperate note for xrays and also if he gives a injection to the pt. there must be a seperate note for the injection too besides dictating the complete office note for billing. We went on the web and tried to find some documentation confirming this but we did not find anything. Do your Docs dictate a seperate note??? Did you ever hear this and if so where is the documentation that this must me done. Help !!!!!!!!!!!
 

nrichard

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I've not been in an office where this has been done. I'm thinking the confusion comes in because when you use modifier 26 you have to have “stand alone documentation of radiological findings”. Some interpretation of this is a separate report. As long as my doctors clearly state the radiological findings separately in their note, I tend not to push this issue. Even my Cardio Thoracic surgeon dictates a separate paragraph or more discussing only the findings separate than the description of the procedure. If your Doc is clearly documenting in his note his description of his/her x-ray findings or office procedure I don't see where he'd need something separately. *note I could be wrong, and if I am hopefully someone can post a link.
 

mitchellde

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on the xrays it is stated in the MCM as well as in the CPT book that an interpretation report must be rendered for radiology. As far as the injections, you do not have to have a separate report per se but you do have to have a separate procedure note which can be in the office note as long as it is identified as the procedure note.
 

nrichard

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@ Debra

Does the radiology interpretation have to be a seperate report or can it be part of the office note (as long as it is dictated in a fashion where it could stand as a seperate report)?
 

mitchellde

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It has to be a separate report. I was part of an audit team from the OIG that audited an Ortho practice the fact that none of their billed radiology charges had separate radiology interpretation reports was a big issue which cause Medicare sanctions for the group.
 
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