Wiki Independent Interpertation

[arkolab]

What all needs to be documented in order to count an independent interpretation/review of an image (i.e x-ray,MRI,CT)? Does the provider need to document date, provider and facility to be able to count it?

 

[JDACPC]

We need to be able to plainly tell exactly which test the doc is looking at, especially if it's something like an ED/inpatient CXR/EKG where they could have multiple per day. "Pt had a CXR at 9am this morning. My personal review of the images show........" or "Pt had an EKG in the ER yesterday which, by my personal interpretation, shows......."

It should be noted if it's from an outside facility. "Pt brought CXR films performed 11/1/24 by his PCP. My interpretation shows...." or "I personally reviewed the CXR images performed at General Hospital on 11/10/24 which show........."

 

[sls314]

I agree with JDACPC, but also wanted to add a link to this article from NAMAS that gives a good description of what's needed to count independent interpretation: https://namas.co/understanding-inde...n-in-e-m-coding-three-essential-requirements/