CODING Q&A

Interpretation and Report: What’s It Mean?

BY SUZANNE CORCORAN, COE

For many ophthalmic diagnostic tests, CPT’s description includes the phrase with interpretation and report.¹ A reader might reasonably ask, what exactly does this phrase mean? And, what kind of chart note is required? Since diagnostic tests accompany almost every eye exam retinal specialists perform on Medicare beneficiaries, this question takes on added urgency. Insufficient chart documentation is reason enough to require repayment of any reimbursement.

So let’s examine just what “with interpretation and report” means.

MEDICARE REGULATIONS AND GUIDANCE

The Medicare guidelines for interpretation of diagnostic tests are in Medicare Claims Process Manual (MCPM) Chapter 13 §100 Interpretation of Diagnostic Tests.² CMS makes a distinction between a review of a test and an “interpretation and report.”

The review of a test is not separately payable because it is part of an E/M service.

Medicare construes simple, brief notations such as “normal” or “abnormal” as a review of the test rather than as an interpretation and report. As a condition of payment,³ 42 CFR 415.120 (a) states:

The value of an “interpretation and report” derives from the answers to these important questions about the diagnostic test:

In ophthalmology, tests such as perimetry are much more valuable for making decisions about treatment when the physician has made a series of them. Then, the concept of “comparative data” cited above is particularly meaningful. Does the series demonstrate disease progression? For a visual field, the “interpretation and report” might read as follows:

WHERE TO WRITE?

The physician can write an interpretation on its own separate page in the medical record or in the blank space on the printout of the test result. Within an electronic medical record, we often find a designated spot to record the physician’s interpretation of a test as a report.

If the interpretation is written as part of the office visit note, it might appear to be an element of the evaluation and management service. Better to keep it separate, or differentiate it from the rest of the eye exam by surrounding the notations with a box and a title like “perimetry report.”

TIMING

Ideally, the physician interprets a test immediately after the technical component is finished. In practice, there may be a delay; however, the delay should not be lengthy or affect patient care. Since many ophthalmic tests require only general supervision,⁴ and the physician need not be present during the performance of the test, the interpretation might take place the next day. If a weekend intervenes, it may be delayed by two days.

It is important to note CMS understands that delays are a fact of life, and, in 2009, proposed regulations to require claims for reimbursement to identify on two separate lines the technical and professional components of a diagnostic test when performed on different dates of service. Transmittals 1823 and 1873 were subsequently withdrawn, yet clinicians are still concerned about this topic.

As a practical alternative, bill the entire test upon completion after the physician documents interpretation in the medical record since it is not clear what diagnosis would be used for the technical component alone.

PAYMENT CONSIDERATIONS

In the Medicare Physician Fee Schedule, different payment rates are established for the professional and technical components of a diagnostic test where there is discrete reimbursement for an “interpretation and report.” Respectively, modifiers 26 and TC make the distinction between the professional and technical portions of the test.

As a practical matter, this segregation permits a technician or medical assistant to perform the technical component, with appropriate supervision. However, only the physician can interpret test results. When the practice does not append TC and 26 to a CPT code, then the payer understands that reimbursement is sought for both the technical and professional components together in a single payment.

A REPORT ISN’T ALWAYS REQUIRED

Some tests, such as extended ophthalmoscopy (CPT 92225, 92226) and gonioscopy (CPT 92020), must be personally performed by the physician, and the phrase “with interpretation and report” is not part of their description in CPT.⁵ A notation in the medical record is still necessary, but the character of the note is different. Extended ophthalmoscopy is recorded as a retinal drawing; gonioscopy is usually recorded as a diagram.^6,7

Following a test, your interpretation and report does not need to be book length, but it must answer pertinent questions about the service. A cryptic, one-word note is not an interpretation as Medicare understands that term. Diagnostic tests are a significant part of most ophthalmic practices, so don’t underestimate the importance of a thorough interpretation and report. RP

REFERENCES