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My Orthopedic clinic is doing in office MRI's and i dont have any experience with radiology beyond xrays. What documentation is needed to bill for them besides the physician order? Do we have to create a whole note with HPI?
Yes, you should have an order (with indication) for the imaging, based on the ordering provider's treatment plan for the patient. The reading provider must do an interpretation and report based on the findings of the MRI. You don't need a SOAP note.
You can bill globally (no modifier) for the MRI if you own the machine. If not, then you can bill only the I&R, using a -26 modifier.