In the retinal subspecialty, diagnostic testing represents a significant portion of services reimbursed by third-party payers. When we perform chart reviews, documentation associated with diagnostic tests is one of the top areas of exposure.

Sometimes indications are not clear, and sometimes orders are missing; the most common problem, however, is documenting test interpretations. Interpretations are often missing completely or lacking in content. In this column, we discuss the documentation standards for diagnostic tests spelled out by Medicare.

ORDERING TESTS

Every test delegated by a physician requires an order. The order, based on physician participation, provides the medical necessity for the test. Strict requirements for a physician’s order exist in the Code of Federal Regulations.

“All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.”¹

Typically, an order for a test occurs after the physician evaluates the patient, which is most often the case for new patients. For established patients, test orders are often noted on the preceding exam as part of the plan for a return visit. In contrast, there are some scenarios that may also support an order even when the physician has not yet examined the patient.

• The retina specialist receives a copy of chart notes from a referring ophthalmologist asking for a consultation and, after reviewing the referring ophthalmologist’s chart notes, the retinal specialist orders a diagnostic test to be administered upon the patient’s arrival.
• Your technician takes a history and performs a preliminary work-up on a new patient, and finds something concerning. The technician brings the information to you, the retina specialist scheduled to see this patient soon, and you order an immediate diagnostic test based on the information.

A test personally performed by the physician does not require an order. For example, extended ophthalmoscopy cannot be delegated to ancillary personnel, so an order is not necessary — assuming the indications support the test, the ophthalmologist personally performs the test.

Avoid the use of standing orders. Retina specialists understandably see patients for specific conditions, but establishing a protocol based solely on being a retina specialist does not support an order. Diagnostic test orders should be specific to a patient and generated on a case-by-case basis.

INTERPRETING TESTS

The phrase “with interpretation and report” is part of the Current Procedural Terminology (CPT) description for many ophthalmic diagnostic tests. We are often asked, “What exactly is meant by this phrase, and what kind of chart note is required?”

Because diagnostic tests accompany almost every eye exam performed by retinal specialists, this question takes on added urgency because insufficient chart documentation is reason enough to require repayment of any reimbursement. It also brings increased scrutiny from Medicare and other third-party payers.

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

“Carriers generally distinguish between an ‘interpretation and report’ of an x-ray or an EKG procedure and a ‘review’ of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the … evaluation and management (E/M) payment.”²

The review of a test is not separately payable because it is part of an office visit.

“For example, a notation in the medical records saying ‘fx-tibia’ or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ‘interpretation and report’ should address the findings, relevant clinical issues, and comparative data (when available).”²

As noted, brief notations like “normal,” “abnormal,” or “stable” are construed as a review of the test rather than as an interpretation and report. Define “normal” for each test and use that definition when you have the occasional normal test results. Noting only the diagnosis as an interpretation is also deficient.

Do not overlook a comparative statement regarding the results. Many of the tests retinal specialists order track changes in chronic conditions like AMD and diabetic retinopathy. Consider answering the following questions for a test interpretation:

• What are the results of the test?
• What do the results mean?
• How do the results compare with any previous test(s)?
• What are you going to do about the results?

For example, for an OCT, the most common test ophthalmologists billed within the Medicare program, the “interpretation and report” might read as follows:

• Subretinal fluid with pigment epithelial detachment OD.
• Increased subretinal fluid showing new active wet AMD since last exam 6 wks ago.
• Recommend anti-VEGF injection OD.

Diagnostic tests are a significant part of most practices, so do not underestimate the importance of an obvious order and a thorough “interpretation and report.” RP

REFERENCES

1. Centers for Medicare and Medicaid Services. 42 CFR 410.32. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: conditions. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/downloads/410_32.pdf . Accessed May 23, 2017.
2. Centers for Medicare and Medicaid Services. Interpretation of diagnostic tests. In: Medicare Claims Processing Manual, Chapter 13 - Radiology Services and Other Diagnostic Procedures. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf . Accessed May 23, 2017.