To accurately assign a CPT code for radiology services, the requirements include original images and a written report that describes the findings. This standard ensures that the necessary documentation of the procedure is complete and meets coding and billing compliance.
A written report is critical because it serves as the official record of the interpretation of the images taken during the radiology service. This report must detail the results of the imaging study clearly enough to support the medical necessity of the procedure and justify the billing codes used. Furthermore, having the original images maintains the integrity of the service provided and supports the conclusions drawn in the written report.
These two elements—original images and a detailed written report—also help in reducing disputes with payers about the service provided and can support appropriate reimbursement for the services rendered. Thus, the emphasis on having both components ensures that documentation standards are met, which is essential in medical coding and auditing practices.