10/14/2026

Coding & Compliance Update: Billing an Imaging Service and an E/M on the Same Day 

Multiple third-party payers are more strictly enforcing documentation requirements associated with submission of radiology services. When both a radiology CPT® code and E/M service are submitted for the same patient on the same day, both an order for the imaging and a full written interpretation must be documented.

The order documentation should include the patient’s name, the study being ordered, anatomy being addressed, number and type of views, the clinical indication(s) for the imaging, and the ordering provider’s name and signature.

The interpretation documentation should include all findings, both pertinent to the chief complaint and not pertinent to the chief complaint, and what decisions were made as a result of the imaging. 

Learn more about this topic at: Radiology Services: Coding and Documentation.