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.