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.

 

[apoland]

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.

Thank you Dr. Raizman. How are you handling the new requirements from UHC for commercial plans when patient has a same day E/M and x-ray?

 

[NRaizman]

AAOS, along with multiple other specialty societies, has been aggressively lobbying against this, has written letters protesting the policy as leading to an undue administrative burden which will have no positive effect on outcomes.

There are lots of workarounds, but they all will likely require backend staff to extract the radiology portion and submit it separately for reimbursement until UHC relents on the policy.

This is also being battled in statehouses and with state insurance boards around the country.