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Thread: Xray reporting - seperate note vs included with office notes

  1. #1

    Default Xray reporting - seperate note vs included with office notes

    AAPC: Back to School
    I have a question regarding xray reports. We are transitioning from one EMR to another. Our physicians read their own xrays and in the past we have always had a seperate xray report from what is also dictated in the body of the office note. We are having some issues with our new system doing this task. Is it imperative that we have two seperate xray reports or will the one in the chart suffice? Does anyone know if there is a legal issue with this?

    Thank you and any input you may have would be greatly appreciated.

    Monica Lanning

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    The radiology interpretation must be its own radiologic interpretation report.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    Louisville, KY


    In addition, the ACR (American College of Radiology) recommends in its practice guidelines that an interpretation report should be rendered. The resource listed below demonstrates the recommended format for those reports.


    Sometimes this type of information is more meaningful for the providers than "reimbursement" requirements for documentation.

    Hope this helps.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  4. #4


    Yes you do have to a seperate dictated report for the x-ray. We had that problem with our ortho's wanting to include it in the office note and no they can not. Also be careful that they are not copying and pasting from the office note and calling it an x-ray dictation

  5. #5
    Join Date
    Apr 2007


    THe OIG has just published a report on their review of diagnostic radiology services in the ER. I think if you review this report you can get a good feel for where they are going with this. and what they consider to be acceptable.

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