Properly document imaging even when it’s bundled into procedure code

Why This Topic Matters

Accurate imaging documentation affects whether bundled services are properly supported in the medical record and whether radiology-related reporting meets CPT requirements. The guidance is relevant to compliance, audit readiness, and consistent documentation practices across diagnostic and interventional settings.

Article Sections

1. 2019 CPT imaging documentation guidance

   Introduces the updated CPT manual guidance related to radiological imaging documentation and how it affects services with bundled imaging components.

2. Imaging guidance and documentation expectations

   Summarizes the broad documentation elements discussed for imaging guidance, including recordkeeping and how imaging support is reflected in the medical record.

3. Supervision and interpretation, imaging guidance

   Covers the CPT radiology guidance on bundled imaging services and the general documentation elements associated with radiological supervision and interpretation.

4. Written report(s)

   Describes the radiology documentation guidance related to written reports and the expectation that patient-specific information appear in the record.