Wiki Independent interpretation

[colleen2282]

I have a provider questioning what is needed to meet independent interpretation. Patient was seen outside of our practice by unrelated office and but refers to the dexa scan ordered by outside provider, Clearly my provider has obtained and looked at the results and has come to a conclusion of his own and that patient is not receiving proper treatment at the other office. please let me know if you think the following documentation qualifies provider for a moderate in the risk category.


Reviewed prior documentation, labs, imaging
Based on prior DEXA scan, she is high risk for osteoporotic fracture (T score -2.7 right femoral neck, FRAX 23%/hip 8%). Reasonable to consider her high risk for fracture. However she is currently only on a conservative management plan through bone health institute. Recommend pt speak with them and tell them her PCP recommends pharm tx. Pt to regroup and let myself know if she would like to pursue tx if the bone institute declines addressing this further. Of note her fracture risk had increased from 2020 to 2021. Given high risk nature of her prior DEXA, can even consider referral to endo if she would like.
Right subscapularis likely strained, will refer to PT given chronicity and lack of improvement of sxs
Skin lesion - likely benign, pt to monitor if it changes in size/characteristics
Pt does do regular self breast exams s/p mastectomy 2/2 DCIS.

 

[csperoni]

This statement seems like the provider read the report/findings, not read the actual images/scans. To count independent interpretation, your provider would need to look at the actual images and determine their own conclusion. I don't recall ever encountering a provider re-reading a DEXA.
Independent interpretation is more common for orthopedists, surgeons, or anyone doing a "wet read" of an xray before radiologist report (in my experience).
The current (as of 3/1/2023) AMA definition is:
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. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.

Examples I have seen that I would credit 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."