Is a Separate Report Really Required?
by Cheryl Nash
Here at American Physician we do quite a few chart and documentation reviews. As a full service billing company, we also provide appeal services and see the feedback from the payers after submitting the provider’s documentation. One of the common issues we see here is in regards to the Ultrasound Reports.
Often times the report sent over is a worksheet from the US technician, without a formal ‘read’ to accompany it. When a provider is asked for the formal report, the question I am asked is “do I need one?” All the information is on the sheet we sent you.” The answer to this is “Yes”, a formal report is invariably needed. The worksheet is an outline or a preliminary report only to assist in generating a formal report.
The requirements for radiological service are comprised of 2 elements; the Technical Component (TC Modifier), and the Professional Component (26 Modifier). The technical component includes equipment, supplies, technicians, and the facility. The Professional Component is the interpretation. When billing globally, the Provider is reimbursed for the technical portion, as well as the interpretation of the results and the report.
An official interpretation or final report must be generated regardless of the site of service (hospital, imaging center, physician office, etc.). The final report is distinctly separate from the notes provided by the technician, or preliminary worksheet. It is the definitive result of an imaging procedure, and should be completed according to State and Federal guidelines. It should accompany or make reference to the images stored within the practice records, and should be available upon request.
As the final report is a portion of what is being reimbursed in the professional component, it stands to reason that it must be a part of the chart to provide complete documentation, or be considered fraudulent billing. It is also a key piece of communication providing the rational for a diagnosis, and potentially further treatment. A worksheet is at times difficult to read owing to handwriting issues, abbreviations, and internal communications that do not translate outside the office. It should be considered a preliminary report only, and never kept as the official report. As in the case of all potentially illegible documentation, a clear official report detailing all findings should be generated to avoid the possibility of denials, or more exciting, failing an audit.
The ACR has suggested documentation guidelines for reporting on acr.org, under the title: ACR Practice Guideline for Communication of Diagnostic Imaging Findings. This is a great resource to assist in formulating a comprehensive reporting policy for your office.
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