MRI and tomography documentation requirements

Q.

If we are billing only with the TC modifier for CPT® code 77014 or CPT code 76498, what are the documentation requirements? The codes and full descriptions are as follows:

76498 Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

77014 Computed tomography guidance for placement of radiation therapy fields

A.

 Your records should indicate that the exam was performed, and you should have permanent images to support this. Many facilities have a short note with the patient information that XXX exam was performed at the request of Dr. A for treatment planning.