The Charting Rules of Diagnostic Radiology

Good charting is becoming a significant requirement and not a luxury. Your ultrasound reports are often the decider between a paid claim and a continued denial. There are some great resources out there on charting for diagnostic radiology, which this article will provide, but I will summarize the basics.

The rules can be set out as follows:

  1. Orders
  2. Interpretation
  3. Documentation
  4. Document Retention

Orders

The rules can be different for hospital services. We are focusing on independent diagnostic testing facilities (IDTF). The Requirements for Ordering and Following Orders for Diagnostic Tests rule by CMS defines a testing facility as “a physician, group of physicians, or IDTF that furnishes diagnostic tests to a Medicare patient.” This rule states that all diagnostic tests must be ordered by the treating physician or practitioner for an individual that is not a hospital in-patient or out-patient. CMS defines treating physician as a “physician who furnishes a consultation or treats a patient for a specific medical problem, and who uses the results of a diagnostic test in the management of the patient’s specific medical problem,” and a treating practitioner as a “nurse practitioner, clinical nurse specialist, or physician assistant, pursuant to state law, who furnishes a consultation or treats a patient for a specific medical problem, and who uses the results of a diagnostic test in the management of the patient’s specific medical problem.”

An order is defined as a communication from the treating physician/ practitioner requesting that a diagnostic test be performed for a beneficiary. This can be in a written format, a telephone call, or an electronic email. If via a telephone call, the content of this must be documented in both the physician record and the record for the testing facility. Standing orders are not acceptable, and all additional tests must also have documented subsequent orders unless detailed under the radiological exceptions. Additional information can be found at cms.gov pub 100-02 transmittal 80.

Interpretation

Next is the Interpretation. The test has been performed either by a facility outside your office, or more likely within your office by yourself or a qualified technician. You may receive an interpreted report form an outside source, or you may interpret it yourself. Either way, this needs to be performed by a qualified physician or practitioner.

Documentation

The interpretation needs to be documented in a formal radiology report. This portion seems to be missed in more cases than not. Payment for radiological services comes in 2 parts. The first is the technical component (TC) which consists of the equipment and physical test. The second part is the professional component (modifier 26), or read, and can be paid for separately. When doing services in house, both are submitted and paid for in the global code.

Guidelines for E/M reporting state you must have a separate report if a radiological interpretation is made. It should not be an addition to the E/M report. This should only summarize the decision making process that includes the test results. There are many tools to assist in the reporting process, and my favorite is from the ACR in their document:
ACR PRACTICE PARAMETER FOR COMMUNICATION OF DIAGNOSTIC IMAGING FINDINGS .
The report should be complete and concise, with all relevant findings listed and interpreted to the highest level.

Documentation Retention

All imaging studies require record retention with a copy to remain on file based upon your state laws. HIPPA requirements state that records need to be maintained for 6 years from the date of creation or the date when it was last in effect, whichever is later. Medicare requires records to remain on file for a period of 5 years, and state requirements are preempted if they are shorter. Some states may be longer. Federal guidelines are available through AHIMA. State resources are pretty easy to find by searching their government pages, can be requested through the state licensing board, and some sites put out summary reports, though the accuracy of these is not guaranteed. The average retention timeframe by state is a period of 7 – 10 years, with additional time being mandated for minors.

The ultrasound is an important part of any phlebology practice and a very important part of the rationale for medical necessity. Having a comprehensive documentation process can make the difference between failure and success.

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