E/M Weekly Tip: Laboratory, Radiology and/or Other Diagnostic Test Findings

The review of laboratory, radiology and/or other diagnostic tests should be documented. A simple notation such as "WBC elevated" or "chest X-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report that contains the test results.

For more information, refer to the CMS Documentation Guidelines for Evaluation and Management Services website.