I work in an acute care facility. My question pertains to the surgeon asking that both a 76000 and 73000 be charged. The Op Note only states that the "C-arm was used to confirm placement of our plate, hardware and our reduction." There is no mention of a separate xray. I checked with the Radiology department and only six "spot films" from the c-arm were stored electronically. There are no hard copies of the fluoroscopy pics nor a separate xray hard copy. I believe we may charge the 76000 for the facility radiology charge but not the 73000 in addition to it. I also would like to verify for compliant documentation, do we need to have copies of the stored shots in the medical chart or is the electronic version o.k.?

Sondra Hayden, CPC, CPC-H