Wiki Independent Interpretation 2023

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RABBIT2020

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One example provided to a coding team for independent interpretation is this statement on a note "....Pending CXR, anticipate discharge once reviewed".
As per AMA guidance on independent interpretation would you say that this is considered an appropriate example.
I cannot seem to fathom from that statement what was interpreted.
Please provide an explanation.
 
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Hi SR2020
I agree not telling you much other than...pt getting chest xray and hopefully think it is normal then complete discharge. Not appropriate final discharge. Is the chest xray completed? If so he or she needs to give you better discharge summary. Maybe this to be a historical note the provider is working on it till pt s x ray is read and can give a proper discharge summary.
Well that is my 2 cents on the matter
Lady T
 
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If you are asking if the statement provided qualifies to count as independent interpretation of tests under the data element, my answer is no. Per AMA:
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
I am guessing the provider wants their "pending CXR, anticipate discharge once reviewed" to count as independent interpretation, but it does not. Independent interpretation would not apply for a provider reading a radiology report. It would mean the provider viewed the actual films/images and formed their own conclusion about the findings, and documented that. Don't forget if this provider ordered the CXR, the order was already counted and review is included.
What would I count as independent interpretation? Something like "I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
 
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csperoni said:
If you are asking if the statement provided qualifies to count as independent interpretation of tests under the data element, my answer is no. Per AMA:
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
I am guessing the provider wants their "pending CXR, anticipate discharge once reviewed" to count as independent interpretation, but it does not. Independent interpretation would not apply for a provider reading a radiology report. It would mean the provider viewed the actual films/images and formed their own conclusion about the findings, and documented that. Don't forget if this provider ordered the CXR, the order was already counted and review is included.
What would I count as independent interpretation? Something like "I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pendinIg.
Click to expand...
 
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csperoni said:
If you are asking if the statement provided qualifies to count as independent interpretation of tests under the data element, my answer is no. Per AMA:
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
I am guessing the provider wants their "pending CXR, anticipate discharge once reviewed" to count as independent interpretation, but it does not. Independent interpretation would not apply for a provider reading a radiology report. It would mean the provider viewed the actual films/images and formed their own conclusion about the findings, and documented that. Don't forget if this provider ordered the CXR, the order was already counted and review is included.
What would I count as independent interpretation? Something like "I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
Click to expand...
To follow up on this, what if the provider reviews the images and states "mild right hydronephrosis" as their interpretation but also states that they also reviewed the report. Could their interpretation still be counted even though they also reviewed the report? (Obviously wouldn't count both the report and interpretation)
 
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As long as documentation states the images are reviewed, and findings noted, I would not see any issue with also reading the report. Something like: "I personally viewed the abdominal ultrasound images from 03/02/2023 and agree with finding of mild right hydronephrosis, which is also documented in the report reviewed."
Here are actual examples from charts I counted as independent interpretation:
"I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
"Images from MRI of abdomen and pelvis 1/22/23 viewed on PACS. Based on the location and size of fibroids, I recommend a laparoscopic vs vaginal approach."
"Patient's left knee MRI from last week has not yet been read. I viewed the images which demonstrates a compression fracture of the lateral femoral condyle. Will confirm with radiologist."
This all of course, is assuming your practice is not billing the test itself.
 
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csperoni said:
As long as documentation states the images are reviewed, and findings noted, I would not see any issue with also reading the report. Something like: "I personally viewed the abdominal ultrasound images from 03/02/2023 and agree with finding of mild right hydronephrosis, which is also documented in the report reviewed."
Here are actual examples from charts I counted as independent interpretation:
"I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
"Images from MRI of abdomen and pelvis 1/22/23 viewed on PACS. Based on the location and size of fibroids, I recommend a laparoscopic vs vaginal approach."
"Patient's left knee MRI from last week has not yet been read. I viewed the images which demonstrates a compression fracture of the lateral femoral condyle. Will confirm with radiologist."
This all of course, is assuming your practice is not billing the test itself.
Click to expand...
Perfect, thank you so much!
 
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