X-ray documentation in EHR

Dduke

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I am in need of some help with a question that has come up with several physicians at our practice. they would like to know if they need to dictate a seperate report for the x-ray reports ( they own the machine and all share medical records thru our EHR system). we were told that all you had to do when you had completed your x-ray is to document the findings in the office visit notes. if there is a policy in regards to this rule could you please forward me to this site.
Thanks for your help!
 

mitchellde

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Yes there has to be a separately documented interpretation report. This is stated in the CPT book, on the AMA website and in the Medicare policies.
 
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Glendale
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Xray interps in EHR

Correct - you must document a separate interpretation. We created a template in our EHR that the doctors use and title it "Chest X-Ray Interpretation" this way it is easily identifiable from the note but both are in the patient EHR chart. So bascially they are opening two encounters if an x-ray was performed in your office. No need to dictate and then scan in -use your system!

Remember they have to document how many views the x-ray was. This has been coming up for us with our payers and if they don't document the views they will down code and pay only a single view :(
 
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