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documentation of x-rays

  1. Default documentation of x-rays
    Medical Coding Books
    There are many times in the physician's clinic documentation he'll state "x-rays of the knee"" shows DJD of the knee. But on the charge ticket what is marked is "3 views knee" and "Knee-bilateral standing". The physician checks off the charge ticket and that is the nurse's order to do the xray. X-rays are done in the clinic. Does the physician need to state specifically in his documentation the exact # of views of the knee and that a "Knee-bilateral standing was also done? Please clarify so I can bring this to the physician's attention.

  2. #2
    Yes because if he does not specify the # of views in his medical record it is left to the clinic's judgement on how many views to do which is not permitted. The clinic does exactly what the doctor orders so the doctor needs to document that. Likewise, proving medical necessity of the knee x-ray (3V) is a must.

    Hope this helps

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