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Documenting Radiology Services in 2019

CPT has again clarified the guidelines for reporting imaging and radiology supervision and interpretation codes. CPT guidelines have specifically required image documentation in the patient record for all radiology services including guidance services. The revised guidelines add a provision that the images contain "anatomic information unique to the patient for which the imaging service is provided." Images refer to those obtained in either a digital or analog manner.

The revised guidelines also address "non-imaging" modalities. Guidance should only be reported when imaging modality (eg, radiography, fluoroscopy, ultrasonography, MRI, CT or nuclear medicine) is used. It should not be reported for the use of a non-imaging-guided tracking or localizing system (eg, radar signals, electromagnetic signals).

When imaging guidance is included in the performance of the procedure, the procedure report should include a notation that imaging guidance was used. For other "radiological supervision and interpretation" codes, there must be a procedure report or separate imaging report that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service. As noted above, image documentation is required for all services.

Your practice should verify there is a process for maintaining all images and that documentation of all imaging services meet CPT guidelines. Adherence to the CPT guidelines and requirements will help ensure that all services are supported in the event of a payer inquiry or request for records. 

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