Wiki x-ray findings and documentation

[EricaWildinger]

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!!!

 

[mitchellde]

In the CPT book in the radiology section at the very beginning it states that the findings need to be separately documented as a radiology interpretation report.
Also in the Medicare manual it states that there must be a separate radiology interpretation report.
I know there used to be a standardized format for these reports that they all had to be in the same format.
I do not see how he could dictate his findings in the orders as he would not know the findings at the time he orders the test, but you should have a section for "result" or "interpretation"

 

[EricaWildinger]

Thank you so much for your response! I will see if I can find it in the CMS manual and move forward from there.