Help! Can You Clarify Radiology Documentation Requirements?

Question:

We are just looking for clarification of the Interpretation for Radiology services. We have been including them in our E/M notes for years. Can you please explain exactly what it is payors like UHC are requesting/requiring? Are they wanting a report of that Radiology exam on a separate form altogether?

Answer:

You're not the only one who has been including the interpretation in the E/M.

CPT guidelines in the introductory section of the radiology chapter 70000-79999 states a written report signed by the interpreting individual is considered "an integral part of a radiologic procedure or interpretation." This means radiology interpretation requires formal, separate documentation—not just findings mentioned within an E/M note. The written report must contain interpretive findings and documentation of the imaging performed.

The CPT exception is if the CPT code includes imaging. For example, CPT 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting includes image guidance. Since the imaging is part of the procedure, you document the imaging guidance within your procedure note rather than as a separate radiology report.

This is also consistent with CMS where the payment conditions for radiology services where Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures states: "The interpretation of a diagnostic procedure includes a written report.”

*This response is based on the best information available as of 01/22/26.