Exam Dictation Documentation Requirements -  Summer Refresher

The tips listed below will help provide the proper documentation to optimize reimbursement for your work and provide the proper support for insurance appeals and potential government inquiry.

Number/Type of Views

Documentation of number and type of views on a diagnostic exam is imperative. If there are separate CPT codes for different combinations of views (e.g., chest x-rays) or different numbers of views (extremity x-rays), the radiology report must indicate which combination or number of views were performed.

Contrast Documentation
If procedures can be performed without contrast, with contrast, or without contrast followed by with contrast images, the report header must specifically describe what was performed. The American College of Radiology recommends including the concentration, volume, and route of contrast administration when applicable.

Doppler US Requirements

In order to bill for a diagnostic non-invasive vascular ultrasound, the following information needs to be documented:
• B-mode or 2D gray scale imaging of the vascular structure AND
• Doppler spectral analysis and color

Separation of Exams
The radiologists should properly identify separate procedures in a report. If separate, distinct, and complete studies of different body sites are performed, then each study should be dictated in separate reports or under separate headings within one report. This will help coders identify all procedures performed and ensure that radiology practices are not disadvantaged during an appeal or audit.

Please contact Jennifer Bash, Debby Crow, or your practice manager for more information on exam documentation and coding.

With best regards,
Jennifer Bash, RHIA, CPC, CIRCC, RCC
Coding Documentation & Education Manager