Xray Order and Interpretation

[apoland]

Hello,
I have a question regarding x-ray reporting. We own and operate our x-ray equipment and have been looking into the requirements for orders/reporting. My understanding is that the order itself must be a separate document that includes demographic info, study ordered including # of views and anatomy, clinical indications, name, and credentials of the ordering provider, but does not require a signature. The report must include demographic information, study performed including # of views and anatomy, clinical indications, findings/impression, limitations if applicable, name, and signature of provider reading films. Please correct me if I am wrong.
Because we are billing the global package for the x-rays, are we able to build the necessary items into a separate section of our E/M for the report or does it need to a be a separate document like the order?

Appreciate any assistance. Thank you!

 

[NRaizman]

This has more to do with individual payor requirements than any national standard for documentation.
Some payors have attempted to demand separate printed/signed reports for radiographs, which confounds most current EMR systems. This led to pushback and most payors have backed off the requirement.

In our orthopaedic practice, we are not generating a separate order, nor are we generating a separate report - they remain embedded within the clinical note used for E&M purposes.