Radiology Reports

Question:

Earlier this year, I attended an education session (not provided by KZA) where radiology reports were discussed. We have been going to KZA courses for many years and have the workbook pages with the history of the requirement and definition change for reports. We were confident we knew the documentation requirements but thought maybe something has changed; we are coming back to KZA for clarification.

In the session, the presenter addressed the need for separate reports; but then said it would be okay if the interpretation was within the office note and not a separate report.

Is a separate report required or not when we report the global radiology codes or the radiology codes with a modifier 26? I just want to make sure nothing has changed.

Answer:

Thank you for your continued support of KZA. Yes, a separate stand-alone report with the professional interpretation (not just review of the X-Rays) is still required. Perhaps the presenter was talking about the documentation requirements when the professional interpretation of external diagnostic studies is documented as part of the E&M note; this interpretation is not separately reportable with a modifier 26; as such a separate stand-alone report is not required. All other interpretation requirements must still be met.

A separate stand-alone report is required if you are billing the global radiology codes or the radiology codes with a modifier 26.