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Documentation Needed for Radiology Coding

  1. Default Documentation Needed for Radiology Coding
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    My physicians do fluroscopy, ultrasound and stereotatic guidance for many of there surgical procedures. We code the professional component for 77001-26, 76942-26 and 77031-26.
    They incorporate the interpretation of these procedures within the surgical report.
    In some reading that I have been doing, I'm not sure if this is correct.
    Does this portion of the procedure have to be documented on a separate paper?
    Also, is there any examples of how the documentation should read that I can show my physicians.

    In a separate quesiton I am also looking for documentation for radiology procedure 93971 as well.

    Any help would be greatly appreciated.
    Marci Klaubauf,CPC

  2. #2
    I am not sure exactly what you are asking in your first question but I may can help with the 93971. Duplex exam incudes imaging...

    Acceptable documentation for Duplex exams:
    Duplex / Duplex Doppler
    Color flow Doppler and spectral analysis was performed
    Color flow Doppler and waveform analysis was performed

    NOTE: Ankle/Brachial Index is not separately billed if performed by itself

    All US exams require documentation of permanently recorded images.

    (This is my understanding)

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