I work for an Orthopedic office we just started to code the x-rays, the mid-levels cannot read the x-rays so the doctors have to read it and dictate a separate x-ray report for me to code.

My understanding is that they have to dictate a diagnosis for that x-ray, also it is my understanding that I cannot use the diagnosis from the mid-levels report for the x-ray that the doctor dictated. I also understand that I can not use anything from the x-ray report to use as a diagnosis because the doctor has to interpret it and come up with a diagnosis.

Does the diagnosis on the mid-level report need to match the doctors diagnosis.

Can anyone let me know if my thinking is correct. We are trying to educate the physicians on the proper procedures.

Thank you,
LLR