Coding Q&A

Mastering the Three C's of Interpretation and Report

Q. I have been hearing that I need a separate interpretation and report for each diagnostic test performed. Our retina practice always does fluorescein angiography and fundus photos at the same time. Is my dictation for the fluorescein angiogram not sufficient?

A. You need an interpretation and report for each test.

Each test that you bill must have an order documented in the chart, as well as a separate interpretation and report. If you perform, bill, and are paid for both fluorescein angiography and fundus photos, then you must have a separate interpretation and report for each test.

The way many retina specialists dictate their reports does not suffice for Medicare as an interpretation and report. Just dictating a diagnosis and "early phase" or "late phase" is not what Medicare requires. You must provide The Three C's.


Clinical Findings. The interpretation and report should succinctly summarize your clinical findings. It does not have to be lengthy — just the pertinent findings. It should not be scribbled within the body of the examination where it looks like part of the examination. It should not be scribbled on the back of the test. Auditors will miss it and you will be challenged.

Comparative Data. Medicare always likes to know if something is better, worse, or just the same as before. This is true for interpretation and report requirements. If a vitreous hemorrhage has resolved, choroidal neovascularization has progressed, or a lesion size has changed, then these findings need to be noted.

Clinical Management. Documenting the effect of the diagnostic test on your clinical management is the area that is almost always lacking in the interpretation and report. Medicare wants to know why it is paying you extra for a test, be it extended ophthalmoscopy, fluorescein angiography, or OCT. You must address how this is going to help you or affect your clinical management. Are you going to change/increase/stop medications? Are you going to recommend surgery? Are you suggesting further diagnostic testing? The answers to these pertinent questions need to be part of your written report.

Do not forget, you must have an audit trail in your chart when you are using digital imaging. With digital imaging I have consistently found that under audit there is no audit trail and often no interpretation and report. Thus, there is no indication that the test was ever performed. Under audit, monies have been paid back to various insurers because of this.

A good example of this emphasis is found in the Local Coverage Determinations for Empire Medicare. Look 1 or 2 up, It is quite clear:

Q. We would like to incorporate most of our retina procedures in our Ambulatory Surgery Center (ASC), but are afraid of going over the 90-minute limit for procedures. Our most frequent coding combination is 67108 (Repair of retinal detachment; with vitrectomy, any method, with or without gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique)and 67038 (Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping). This usually averages 2 to 3 hours operating time. How can we get around that?

A. This is really not a problem because the "90-minute rule" that you are referring to is just a criterion for a given procedure to be included in Medicare's List of Approved Procedures for ASCs.

There is a list of criteria that must be adhered to in order for a given procedure code to be incorporated into the list. Because both of these procedures are on the list, they may be performed and are reimbursable in the ASC setting.

When reading the rules for ASCs, you have to differentiate what is a rule that applies to performance of the procedure and coding of the procedure vs. what are simply criteria for a given CPT code to be included on the list.

CPT codes copyright 2004 American medical Association.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at