X-Ray Interpretations

Documentation Tips: X-Ray Interpretations

Documentation Tips: X-Ray Interpretations

Radiographic studies contribute to the complexity of medical decision making when they are documented properly and can be billed separately when they contain sufficient content.

Interpretations should be written each in their own paragraph.  Include the following:

  • Type of views/projections taken (PA, lateral, oblique, 3 views, 4 views, etc.)
  • Specific description in precise anatomic language of the imaged organ or body area.
  • Specific location and extent of any pertinent positives
  • Conclusions on what was suspected, what was found (e.g., no infiltrate, no definitive masses, calculi, or, no fracture/no bony deformity)
  • Who provided the initial interpretation (‘read by me’,’ my interpretation is…’).  

Notes like ‘Normal’, ‘No acute disease’, or ‘No fracture’ would not qualify as billable interpretations because they contain only the pertinent clinical finding and do not describe the views and anatomic location.  At least 3 comments on every chest and abdominal film and 2 comments on all other films would minimally qualify as a professional interpretation.

For pre- and post-reduction films or any repeated studies state separate interpretations for each.

Examples of billable X-Ray interpretations:

  • Chest X-Ray For Shortness of Breath Complaint:‘2 view chest films reveal no infiltrate, no interstitial markings and no cardiomegaly as read by me.’
  • Chest X-Ray For Patient With Generalized Complaint: ‘Per my interpretation, PA and lateral films reveal bones: well corticated, no DJD, no lytic lesions, no rib fractures; heart size: normal; lungs: no pneumothorax, masses or hyperinflation, possible early left lobe infiltrate; mediastinum: not widened, no tracheal deviation; aorta: normal.’
  • Abdominal X-Ray For Generalized Complaint: ‘3 view abdominal films (flat and upright) reveal bowel gas pattern: no ileus, obstruction, air-fluid levels or free air; kidneys: bilateral kidney shadows visualized, no mass or abnormal calcification noted; aorta: no significant calcification or enlargement visible on plain film; bones: no bony abnormality noted. Read by EP.’
  • Ankle X-Ray For An Injury: ‘3 view ankle films reveal mild displacement of the ankle mortise and soft tissue swelling but no fracture as read by me.’
  • Shoulder X-Ray For Possible Fracture: ‘4 view shoulder films reveal a midline clavicular fracture, no other bony deformity and no soft tissue damage as read by me.’

If the practice normally bills for x-ray interpretations and documentation does not meet aforementioned requirements, the X-ray interpretation will not be coded/billed and deficiency code 8165 will be assigned for tracking purposes.

Examples of billable X-Ray interpretations:

  • Chest X-Ray For Shortness of Breath Complaint:‘2 view chest films reveal no infiltrate, no interstitial markings and no cardiomegaly as read by me.’
  • Chest X-Ray For Patient With Generalized Complaint: ‘Per my interpretation, PA and lateral films reveal bones: well corticated, no DJD, no lytic lesions, no rib fractures; heart size: normal; lungs: no pneumothorax, masses or hyperinflation, possible early left lobe infiltrate; mediastinum: not widened, no tracheal deviation; aorta: normal.’
  • Abdominal X-Ray For Generalized Complaint: ‘3 view abdominal films (flat and upright) reveal bowel gas pattern: no ileus, obstruction, air-fluid levels or free air; kidneys: bilateral kidney shadows visualized, no mass or abnormal calcification noted; aorta: no significant calcification or enlargement visible on plain film; bones: no bony abnormality noted. Read by EP.’
  • Ankle X-Ray For An Injury: ‘3 view ankle films reveal mild displacement of the ankle mortise and soft tissue swelling but no fracture as read by me.’
  • Shoulder X-Ray For Possible Fracture: ‘4 view shoulder films reveal a midline clavicular fracture, no other bony deformity and no soft tissue damage as read by me.’

 

Examples of billable X-Ray interpretations:

  • Chest X-Ray For Shortness of Breath Complaint:‘2 view chest films reveal no infiltrate, no interstitial markings and no cardiomegaly as read by me.’
  • Chest X-Ray For Patient With Generalized Complaint: ‘Per my interpretation, PA and lateral films reveal bones: well corticated, no DJD, no lytic lesions, no rib fractures; heart size: normal; lungs: no pneumothorax, masses or hyperinflation, possible early left lobe infiltrate; mediastinum: not widened, no tracheal deviation; aorta: normal.’
  • Abdominal X-Ray For Generalized Complaint: ‘3 view abdominal films (flat and upright) reveal bowel gas pattern: no ileus, obstruction, air-fluid levels or free air; kidneys: bilateral kidney shadows visualized, no mass or abnormal calcification noted; aorta: no significant calcification or enlargement visible on plain film; bones: no bony abnormality noted. Read by EP.’
  • Ankle X-Ray For An Injury: ‘3 view ankle films reveal mild displacement of the ankle mortise and soft tissue swelling but no fracture as read by me.’
  • Shoulder X-Ray For Possible Fracture: ‘4 view shoulder films reveal a midline clavicular fracture, no other bony deformity and no soft tissue damage as read by me.’

 

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