Physicians question why they must document test interpretations if their observations are already documented in the Impression and Plan. This month, we’ll address this issue.

Q. Are there requirements regarding where an interpretation and report must be documented?

A. There is no specific instruction about how to chart, but the interpretation and report must be readily identifiable as separate from the exam. If it is not, then it might appear to be part of the exam. Remember you are being paid for a diagnostic test in addition to an exam, so the documentation for the test must be complete and stand on its own.

An interpretation can be written on its own separate page in the medical record or in the blank space on the printout of the test result. An EMR usually has a designated tab to record the physician’s interpretation of a test as the report.

Q. CPT definitions of ophthalmic diagnostic tests frequently include the phrase, “with interpretation and report.” If the physician always reviews the test output, isn’t this an interpretation?

A. Not really. Simple, brief notations such as “normal” or “abnormal” are construed as a review of the test rather than an interpretation and report. In addition, a comment such as “agrees with exam findings” can imply that the test was not medically necessary because the physician’s exam identified the disease or condition.

The Medicare Claims Processing Manual (MCPM) Chapter 13, §100 states, “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 … E/M payment.”

It goes on to say, “For example, a notation in the medical record 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 date (when available).”

Although the examples in the MCPM are not ophthalmic tests, the same requirements apply.

Q. What documentation is required for a diagnostic test?

A. In addition to the physician’s order and documentation as to why the test is needed, several other elements are necessary:

• Date performed
• Technician’s initials (not required but useful internally)
• Reliability of the test
• Patient cooperation (when applicable)
• Test findings
• Comparison with prior tests (when applicable)
• Assessment, diagnosis
• Impact on treatment, prognosis
• Physician’s signature

In ophthalmology, especially in retina, tests such as optical coherence tomography are much more valuable for making decisions about treatment when the physician has a series to consult. Then, the concept of “comparative data” is particularly meaningful.

Q. What about timing of the interpretation?

A. Ideally, the interpretation of a test follows immediately after the test is performed. In practice, a delay may occur, although it should not be a long delay or affect patient care. Because many ophthalmic tests require only general supervision and the physician need not be present while the test is performed, the interpretation might take place the next day, or a day to two later if a weekend intervenes.

Q. Do all tests require an interpretation and report?

A. Some tests, such as extended ophthalmoscopy, must be performed personally by the physician and the phrase “with interpretation and report” is not part of the definition. A notation is still required in the medical record, although the nature of the note is different.

Q. Does anyone ever get into trouble over this?

A. Unfortunately, yes. We at Corcoran Consulting Group audit medical records. If no interpretation is documented, we usually allow the technical component (TC) of the test, assuming that other supporting documentation is present. However, during a payer audit, it is quite possible that the entire test would be disallowed; the medical necessity is questionable if the physician doesn’t consider the test of sufficient importance to do the interpretation. RP