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Thread: medicare rules for x-ray notes

  1. #1
    Join Date
    Apr 2007

    Smile medicare rules for x-ray notes

    AAPC: Back to School
    Has anyone heard the new medicare rules for x-ray notes? My understanding of this is, If an office sends patients out for x-rays, labs, ect...then our doc would do a separate report from that. but we do all of our x-rays in the office, the doc sees them after the x-ray, and a note is dictated along with the regular office note. I guess my question is..do we still have to have totally separate dictation from the office notes for x-rays if they are done in house?
    Any help is appreciated!!
    Jen P

  2. #2
    Join Date
    Apr 2007
    Kansas City MO


    To bill for the professional components for radiological services there must be a separately dicated report and either hard copies of films or reproducible images in the patients medical records. CMS prefers the interpretation be dictated as completely separate report, but will also accept an interpretation on the same note as the E/M as long as it is carved out under a separate heading.

  3. #3
    Join Date
    Apr 2007
    Flint, Michigan


    I found this interesting as I work in a Podiatrist office and we do our own xrays too. The doctors dictate the findings of the xray in with the dictation of the E/M visit.

    My question is: an xray is done to rule out a fracture and a fracture is found. Do I code the xray for pain as the reason or do I code it as a fracture since a fracture was found after the xray was done? I know if no fracture is found, I code pain as reason for xray. Any help would be appreciated!

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