Codapedia (TM) - The Free Encyclopedia for Medical Reimbursement
Join Our Community Here
It’s FREE!
Field Guide to Physician Coding 3rd Edition


Codapedia Editor
Report for professional component of a diagnostic test
Citations: No citations found
Resources: No resources found
Total Reviews: 0
Current Rating: -na-

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.

Printable Version

If you liked this article, you might like these too...

Click Here to Comment, Clarify and Rate this Article

Field Guide to Physician Coding 3rd Edition
About Codapedia |  Terms of Use |  Privacy Policy |  Management