AMA CPT® Assistant - 2015 Issue 9 (September)
Coding Brief: Changes to "Written Report" (September 2015)
September 2015 page 10 Coding Brief: Changes to "Written Report" In tandem with recent changes in electronic health records, the CPT Editorial Panel conducted a review of the phrase "written report" and performed a search of the entire code set to determine the usage of the phrase. As a result of the CPT Editorial Panel's review, guidelines defining the requirements for written report will be added to several sections of the CPT code set in the CPT 2016 code set to indicate that a written report can be either handwritten or electronic to reflect current practice, as well as...
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Article Overview
This brief article explains a CPT Editorial Panel review of the term “written report” and the related guideline updates planned for CPT 2016. It is relevant to coders, radiology practices, and documentation professionals who need to understand how the revised language affects CPT instructions across multiple sections of the codebook. The article also discusses related guidance for imaging documentation, supervision and interpretation, and where the updated instructions will appear within the CPT code set.
Why This Topic Matters
The update affects how documentation requirements are presented across CPT sections and helps readers stay aligned with current CPT guidance for report and imaging documentation language.
Article Sections
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September 2015 page 10
Publication and article identification details for the CPT Assistant issue.
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Coding Brief: Changes to "Written Report"
Overview of the CPT Editorial Panel review and the planned updates to written report language in CPT 2016.
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Imaging Guidance
Discussion of new guideline placement and how imaging guidance instructions relate to procedures and documentation within CPT.
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Supervision and Interpretation
General discussion of image documentation, supervision, and interpretation concepts as they relate to CPT guidance and report requirements.
What You Will Learn
- How the CPT Editorial Panel reviewed terminology used in CPT guidance
- Where revised written report language will appear in the CPT codebook
- How imaging guidance instructions are organized across CPT sections
- The relationship between supervision, interpretation, and documentation guidance
Who Should Read This
- Medical coders
- Coding auditors
- Radiology coding professionals
- Documentation specialists
- Physician practice staff
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