Coding & Reimbursement

That Ubiquitous Phrase

By Suzanne L. Corcoran, COE

CPT definitions of ophthalmic diagnostic tests frequently include the phrase, “with interpretation and report.” What does this mean? And why should you care?

Q The doctor 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.

The Medicare Claims Processing Manual (MCPM) Chapter 13, subsection 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 data (when available).

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

Q What is required on a test interpretation?

A In addition to the physician’s order and documentation as to medical necessity of the test, the interpretation requires these elements:

• Date performed.

• Technician’s initials (not required but useful internally).

• Reliability of the test.

• Patient cooperation (when applicable).

• Test findings.

• Assessment and diagnosis.

• Impact on treatment and prognosis.

• Physician’s signature.

In ophthalmology, tests such as visual fields and OCT are much more valuable for making decisions about treatment when performed in a series. Then, the concept of “comparative data” is particularly meaningful.

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

A An interpretation can be written on its own page in the medical record or in the blank space on the test result printout.Within an EHR, we often find a designated spot to record the interpretation as the report. If the interpretation is written as part of the exam note, it might appear to be an element of the exam, so we recommend you differentiate it from the rest of the exam by surrounding the notations with a box and note.

Q What about timing of the interpretation?

A Ideally, the interpretation follows immediately after the test is performed. In practice, delays do occur, but they should not be lengthy or affect patient care. Because many ophthalmic tests require only general supervision and not necessarily the physician’s presence, the interpretation might take place within a few days.

Q Do all tests require an interpretation and report?

A Some tests, such as extended ophthalmoscopy and gonioscopy, 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.

Q How serious is this situation?

A We at Corcoran Consulting Group audit medical records. If the record does not document an interpretation, we allow the technical component (-TC) of the test, assuming that other documentation supports the test. However, a payer audit could disallow the entire test. The medical necessity is questionable if the physician does not consider the test important enough to interpret it. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.