Wiki Ortho clinic billing for xray(s)

[MargoR]

Good Morning all,
I started coding for an Ortho Clinic, they perform xray(s) inhouse and our physicians interp the xray(s). The interp (findings) is documented on the progress note, there no seprate note for the xray(s).

Can we bill for the complete xray(s)?

I was advised that xray(s) or any radiology has to have their own report, so separate from the progress note.
If yes or no, any resourse's will be greatly appreciated.

example:

 

[SharonCollachi]

Well, what you have there is not complete, whether it is in a separate report or not (there is not even an indication that xrays were done that day or another day). See this list for what should be included: https://www.aapc.com/blog/27355-quick-tips-radiology-report-requirements/

I am unclear why it would need to be a separate document, but it does definitely need more information than you have. If you had received that info from a reading radiologist you would not consider it acceptable or complete.

 

[MargoR]

Good Morning Sharon, This is in an office setting and all the info is on the progress note.
Patient name:
DOB
Account #
DX -reason for xray
xray order
xray film
xray findings (interp) is on the physicial exam area or in the assessment and Plan
electronically signed off
etc...

I was advised that it should be separate from the progress note, just wanted to confirm.