EricaWildinger
Contributor
I work for a group practice that has it's own x-ray department. One of our physicians won't document his x-ray findings the the "orders" when he orders an x-ray. He just dictates it in the HPI (and that's even questionable as I haven't seen anything remotely indiciative of him mentioning his findings.) My problem is this....the previous coder told him that he COULD do it that way and I strongly disagree. I have found other people questioning the same thing with responses stating they have to separately dictate x-ray findings in their EHR. We have a "tab" for Orders where the physician puts in their x-ray orders and they also dictate thier findings. Where can I find documentation, either in CPT, AMA or CMS that I can show him to "prove" he has to dictate his findings separately?
Please please please help!!!
Please please please help!!!