We currently are using an outside radiologist to read all of our x-rays, therefore we have an official report on each x-ray. If we go back to reading our own x-rays, do we need to have a separate official report made? Or is it sufficient to just put the x-ray findings as part of the SOAP? Also, we are questioning the way we are billing our x-rays. Some of us feel like you should be able to bill for taking the x-rays and then reading them as well.
Technically the x-ray findings do not have to be in a separate report, but, as an auditor, I much prefer a separate and distinct page with all of the essential elements included. There is a nice summary of what that might look like on page 233 of the 2017 DeskBook. Too often I see a SOAP note with a brief mention of the x-rays and it is deficient in terms of explaining the rationale and results of the procedure. Radiology codes actually include a technical component (TC) and a professional component (26). So, if you bill 72100, the reimbursement includes payment for taking the x-rays (technical component) and payment for reading and creating a report (professional component). There is a separate code for consulting on an x-ray taken elsewhere (76140) but that does not sound like it would apply to this clinic. If the clinic is currently taking x-rays, but not reading them, they ought to be billing it as 72100-TC, and the guy reading them would bill 72100-26. Each would get a portion of the full fee.