Documentation Of In-Office Imaging

Upon performing reviews of colleagues’ documentation practices, one consistent deficiency I find is the documentation that accompanies in-office imaging, namely X-ray and ultrasound studies. Each payer may have their own guidelines, but most follow the guidelines promulgated by Medicare in the Medicare Benefit Policy Manual, Chapter 15, Section 80.¹

These guidelines include the requirement of a written order in the medical record for the imaging study. This order must include:¹

• Patient name;
• Test requested;
  • Body part/laterality;
  • Views, number and type for X-rays;
  • Plane(s) for ultrasound;
  • Clinical indication(s) for the test; and
  • Name and signature of the treating physician.

In addition to, and separate from, the above described order, we are also required to document a report of the study performed when submitting for payment for the professional component of the study. That report must include: ¹

• • Patient name;
  • Test requested;
  • Body part/laterality;
  • Views, number and type for X-rays;
  • Plane(s) for ultrasound;
  • Findings;
  • Soft tissue density;
  • Bone quality; and
  • Pertinent findings.

The findings should include those other than just the area of interest.

Even though there is overlap between the requirements of the order and the requirements accompanying the report, it is suggested that these two elements be fully documented independent of each other and titled as “Imaging Order” and “Imaging Report.” Doing so helps an auditor or third party payer representative find what they are looking for in the event of a documentation review.

Dr. Lehrman operates Lehrman Consulting, LLC, is a consultant to the APMA Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Certified Professional Coder. Follow him on Twitter @DrLehrman

Reference

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 15. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf . Revised March 24, 2021. Accessed July 23, 2021.