X-Ray Documentation

Question:

Is it required to have the specific x-ray views noted in the documentation or will the code description of the number of views be sufficient?

Answer:

Thank you for asking KZA! The specific views performed must be documented in the radiology findings. 

Best practice wording example: "X-ray of the left knee obtained 3 views" based on CPT nomenclature.

Clinical Examples in Radiology Fall 2024 describe the views as (eg, AP, lateral, and sunrise, and posteroanterior) views but state "code selection depends on the number (not the type) of views."

Findings: Joint space narrowing with osteophyte formation, no acute fracture. Impression: Degenerative joint disease." 

It is important to document clinical history and confirmed or definitive diagnosis(es). 

*This response is based on the best information available as of 10/23/25.