Wiki X-Ray Question

[LLRodgers]

Hello,

I work for an Orthopedic office we just started to code the x-rays, the mid-levels cannot read the x-rays so the doctors have to read it and dictate a separate x-ray report for me to code.

My understanding is that they have to dictate a diagnosis for that x-ray, also it is my understanding that I cannot use the diagnosis from the mid-levels report for the x-ray that the doctor dictated. I also understand that I can not use anything from the x-ray report to use as a diagnosis because the doctor has to interpret it and come up with a diagnosis.

Does the diagnosis on the mid-level report need to match the doctors diagnosis.

Can anyone let me know if my thinking is correct. We are trying to educate the physicians on the proper procedures.

Thank you,
LLR

 

[Orthocoderpgu]

Are you billing for the Mid-levels?

It's common to have PA's work with the physicians and help out a bit. But if you are ultimately billing for the doctor, I would only use the doctors interpretation for the diagnosis.

The doctor does need to document the diagnosis, and more than just the anatomical location of the fracture (distal radius fracture).

I'm assuming everything is being under the doctors name. As such I would only use their interpretations.

Keep in mind that most of the time the mid-level providers should be working in the doctor's shadow and following their treatment plan.

 

[LLRodgers]

Thank you for your response it is very much appreciated. Yes I am bill for the mid-levels also. Does that make a difference. Also how much should a doctor dictate for the X-ray report, the diagnosis, the interpretation other than the name/DOB/Date of service.

Thank you,
LLR