Coding Q&A

Interpretation and Report Protocol for Diagnostic Tests


Interpretation and Report Protocol for Diagnostic Tests


Q. We are looking at how best to document interpretations of diagnostic tests (fundus photography, fluorescein angiography, or OCT as examples). What documentation is required? What forms have been developed for documentation?

A. This is a serious issue for all practices, particularly the retina practices. Most practices are not in compliance with Medicare's requirements and, yes, there are requirements.

The Medicare Carriers Manual (§15023) specifies that an interpretation and report should address the findings, relevant clinical issues, and comparative data (when available). There must be a written report that becomes part of the patient's medical record and this should be as complete as possible.

The Three C's. An easy way to capture this mandated information is to adhere to the principles of The Three C's – Clinical Findings, Comparative Data, and Clinical Management. Often there is only a clinical description of the findings and the physician erroneously assumes that this suffices. I refer you to the article entitled "The Three C's" on my Web site from which the following is taken:

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, or 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. And this is true for interpretation and report requirements. If a vitreous hemorrhage has resolved, choroidal neovascularization has progressed, or a lesion size has changed — these findings need to be noted.

Clinical Management. Documentation of 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 they are paying you extra for this test — this extended ophthalmoscopy, this fluorescein angiography, this fundus photo. 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.

These answers may be duplicative of information in other areas of the chart, such as the Assessment/Plan. You need to have the documentation is both places.

The report may be on a separate form, clearly documented in the medical record, or part of your dictation. If it is part of your dictation it should be labeled as such — for example, "OCT Interpretation and Report."

I highly recommend that a separate form be used that leaves an audit trail indicating there is an interpretation and report. Particularly in large practices, this becomes more important since it is difficult to obtain uniformity within a practice. You can use a separate form for each test or use a combination form that lists all the tests. You check off the test and then add the Three C's.

There is a particular problem with digital imaging where, in many instances, the images are reviewed without the chart and the physician neglects to provide a written interpretation and report.

One of the most common errors is not having a separate interpretation and report for each test performed. If you are billing separately for any test, then each test needs its own interpretation and report.

Medicare contractors/carriers have been revising their policies to emphasize the importance of having the proper written report. Adhering to a system as described will audit-proof your charts.

CPT codes copyright 2006 American Medical Association. RP

Riva Lee Asbell can be contacted at where the order form for her new book "Tips on Ophthalmic Surgical Coding by Subspecialty" can be found and downloaded under Products/Books.