Documentation for Number of Views for X-Ray Interpretations

KStaten

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Hello Everyone! :)

I need confirmation on documentation for x-rays, please.

Scenario: A physician orders and reviews knee x-rays in his/her office. The orders that appear in the note state the number of views. Does the physician ALSO have to state the number (or specific name/type) of views in his / her interpretation?

My AAPC Codify account states as a tip, "Be sure that the provider’s documentation clearly describes each view taken in a radiology service. Check the documentation for the patient’s body position and projection of the X–ray to assign the correct number of views."

This article from AAPC suggests that the physician must state the number of views in the interpretation report in addition to the orders, as it states "The medical report must state the number of views, AND referring physician orders must indicate the number of views or the name of the specific views desired."
https://www.aapc.com/blog/32399-cou...ogy department or,or she would like performed.

Thank you in Advance,
Kim
 

csperoni

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I interpret that the report must state the number or specific name(s) of views, otherwise you may only code/bill for the lowest number of views. It seems pretty clear and I'm not sure how you would interpret the guidance any other way. The blog link you posted is actually part of a larger article. https://www.aapc.com/blog/26233-seven-tips-for-diagnostic-radiology-coding-success/
Tip 1:
Be Sure Reports Meet Minimum Requirements
To meet ACR guidelines, all dictated radiology reports must contain:
  • Heading (study name)
  • Number of views or sequences (name of views – what was done)
  • Clinical indication (reason for exam)
  • Body of report (findings)
  • Impression or conclusion (synopsis of findings)
  • Physician signature
  • Diagnostic studies (plain films)
 

KStaten

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Thank you for your input and for the additional link. The physician was asking if, as I had stated, his orders appear in the office note/report as the heading (with the number of views and/or names of views) for the x-rays his office conducts and he interprets, if he still needs to restate the number of views and / or name of views directly beneath the order heading. I can understand his reason for questioning, whereas this would seem redundant if he is the one ordering and interpreting the x-rays and the number/views do appear (and are, thus, technically documented) in the report as the heading of the order in the text immediately prior to his interpretation in the report.
 
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