Radiology procedures should contain a written report
Radiology procedures should contain a written report, signed, as a component along with comprehensive documentation supporting the findings. Instructions added to Radiology code section in the CPT(R) 2016 manual confirm, ?A written report handwritten or electronic signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.? Radiology report templates should be structured to facilitate clear, concise, and complete documentation necessary for accurate billing.
Recommended documentation should include, at a minimum (and when applicable):
- Facility or location where the study was conducted
- Name of patient and medical records number
- Name of referring physician
- Type of examination/service
- Date of examination/service
- Time of examination/service
- Injection of dye
- Number of views
- Date of dictation
- Date and time of transcription
- Patient age or DOB
- Patient gender
- Clinical information and diagnosis code (if available)
- Procedures/materials
- Findings
- Potential limitations
- Clinical issues
- Comparison studies and reports
- Impressions
Imaging studies such as magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, nuclear medicine or X-ray exams play an increasingly important role in the diagnosis and treatment of disease. After completing an imaging study, the radiologist will analyze the images and prepare a report summarizing the findings and impressions.
Electronic Health Records
Many patients today can access their health records ? including radiology reports ? electronically online. Electronic access to health records allows patients to make more informed healthcare decisions in partnership with their physicians. Plus, patients are empowered to electronically share radiology reports with other medical providers. This potentially increases the safety, quality and efficiency of patient care.
The radiology report is primarily a written communication between the radiologist interpreting the imaging study and the physician who requested the examination. Typically, this radiology report is sent to the physician who originally requested the imaging study and who then conveys the results to the patient. Many patients can also directly access their radiology reports and, in some cases, their medical images using online patient portals and electronic health records.
These records and reports often contain complex anatomical and medical terms.
CPT(R) is a trademark of the American Medical Association