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Thread: X-ray reports within body of E/M

  1. #1
    Join Date
    Apr 2007

    Default X-ray reports within body of E/M

    AAPC: Back to School
    If a provider is performing a radiology service in his office and including the findings completely in his E/M note, can the radiology service be billed? Is there somewhere that states that there must be a separate radiology report? I have found information saying that to bill the professional component only there needs to be but we're billing globally. I can't find a definitive reference and need to have one to present to the physicians because I think they should be separate. One specific example is for OB ultrasounds, limited and others, where the picture gets filed in the record but the interpretation is within the body of the E/M.

    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  2. #2
    Join Date
    Apr 2007
    Watertown, NY


    No, it doesnt have to be on a seperate report. As long as what is being done is notated (ap lateral views, 14w limited u/s) along with the dr's findings/results. Our practice also makes our doctors state the reason for the x-ray or u/s (less room for confusion). We also have a Radiology section on the actual Progress note. We also use EMR and the result/findings are all on
    1 page.
    chris g,cpc

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