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Xrays in office

  1. #1
    Smile Xrays in office
    Medical Coding Books
    Does anybody have any resources on the specific documentation required for an orthopedic surgeon to do xrays in the office?


  2. Default
    the ortho surgeon I work for does Xrays in the office as well and he just dictates a separate paragraph in the office visit note regarding the interpretation of the xrays and what was done.

  3. #3
    Columbia, MO
    The interpretation is to be on a separate radiology interpretation report. This is stated per the AMA and I believe is in the CPT book in the front of the radiology section. It cannot be a paragraph in the progress note. I was involved in an audit of an ortho practice where this was a big issue.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Medicare Part B Policy Palmetto GBA MAC - J1

    Effective Date

    Publish Date
    June 2008

    States Affected

    Policy Number

    Radiologic Examination, Chest

    "Each payable interpretation must include a complete, written report similar to one that is prepared by a specialist in the field. The content of the written report must address the relevant clinical issues, available comparative data, and test findings. The format of the report must be separately identifiable. It may be included under a separate heading within the clinical record."
    Mary, CPC, CANPC, COSC

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