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Field Guide to Physician Coding 3rd Edition


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Report for professional component of a diagnostic test
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What does a physician need to document and in what format?

If you are a radiologist, you know the answer to this question. 

Many diagnostic tests have both a professional and a technical component.  Whether or not a test has both is found in the Medicare Physician Fee Schedule Data Base.  A physician bills for the global service, with no modifier, when providing both components.  A physician bills for the professional component with a 26 modifier when providing only the interpretation and report.  A group or facility that provides the technical component (performs the test, owns the equipment, hires the staff, etc) bills with a TC modifier, indicating technical component.

Physicians who have diagnostic equipment in their offices, such as EKG machines, x-ray, ultrasounds, etc, and bill for the interpretation and report need to document a separate, radiology quality report.   This includes:

  • the indication for the test
  • the number of views/tracings/or description of the test
  • the findings

It is insufficient to simply write "Normal" affix a signature to a machine generated report. 

What does separate mean?  Can an x-ray report be included in the body of the progress note, or does the interpretation and report need to be on a separate piece of paper?   The important components, (listed above)  must be dictated  or written by the physician in a report.  A simple summary in the progress note is insufficient to bill for the interpretation and report.

The citation from the manuals says:

The interpretation of a diagnostic procedure includes a written report.
 

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Field Guide to Physician Coding 3rd Edition
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