Documentation needed for manual application of stress in joint radiography

Q.

We are wondering if you would provide some guidance regarding the use of CPT^® code 77071 – Manual application of stress performed by physician or other qualified health care professional for joint radiography, including contralateral joint if indicated?  When stress imaging of a joint is performed, in order to charge for 77071 (as well as the joint /anatomic site and # of views) is it necessary that the report specifically document who applied the stress, similar to the ultrasound of infant hips with manipulation (CPT code 76885)?  

A.

Documentation is required somewhere in the patient’s medical record that the stress was provided by the physician or other healthcare provider (NP, PA). It doesn’t have to specifically be in the report, but if you choose not to and you are audited, it’s necessary to remember to send the additional documentation with your report and the order.