Coding

Interpret and report

How much is enough with this code descriptor?

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

I am often asked, “How much is enough?” to document when a diagnostic test has the words “with interpretation and report” in the code descriptor.

Because diagnostic testing accompanies almost every eye exam and insufficient chart documentation is reason enough to require repayment, it’s a good question. Although not all diagnostic eye tests require this extra step, most that result in a charge do.

Medicare regulations

The Medicare guidelines for interpretation of diagnostic tests are discussed in Medicare Claims Process Manual (MCPM) Chapter 13 §100 Interpretation of Diagnostic Tests. CMS makes a distinction between a review of a test and an “interpretation and report.”

This section states: “Carriers generally distinguish between an ‘interpretation and report’ … and a ‘review’ … A professional component billing … without a complete, written report similar to that … prepared by a specialist … does not meet the conditions for separate payment of the service … because the review is already included in the … E/M payment.” It goes on to state: “… ‘interpretation and report’ should address the findings, relevant clinical issues, and comparative data (when available).”

Simple, brief notations such as “normal” or “abnormal” would be considered a “review” of the test and would not qualify. Medicare requires an “interpretation and report” as a condition of payment. The value comes from the answers to some important questions:

• Physician’s order – Why is the test desired?

• Date performed – When was it performed?

• Technician’s initials – Who did it?

• Reliability of the test – Was the test of any value?

• Patient cooperation – Was the patient at fault?

• Test findings – What are the results of the test?

• Assessment, diagnosis – What do the results mean?

• Impact on treatment, prognosis – What’s next?

• Physician’s signature – Who is the physician?

Ophthalmology tests, such as visual fields, are more valuable when there is a series. (Does the series demonstrate disease progression?)

For a 30-2 threshold perimetry, the “interpretation and report” might read:

• January 25, 2016

• Technician: Mary Smith, COA

• 1 false positive

• Good patient cooperation, 1 fixation loss OU

• Arcuate scotoma superiorly, OU

• POAG, moderate stage, OU. Progression since last visit

• Add brimonidine (Alphagan P, Allergan) bid, OU

• Signed: I.C. Better, MD

Where and when to write it

An interpretation can be written on its own separate page within the paper or electronic medical record or in the blank space on the printout of the test result. It is best to keep it separate from the rest of the eye exam to make its value clear to payers.

Ideally, the interpretation follows immediately after the technical component. In practice, there may be a delay, but it should not be lengthy or affect patient care. Bill the entire test upon completion after the interpretation is documented since it is not clear what diagnosis would be for the technical component.

Payment considerations

In the Medicare Physician Fee Schedule, different payment rates are established for the professional and technical components of a diagnostic test where there is discrete reimbursement for an “interpretation and report.” Modifiers -26 and -TC are used to make the distinction between the professional and technical portions, respectively. Only the billing provider using the results can perform the professional portion. When -26 and -TC are not used, then the payer understands that reimbursement is sought for both.

Do all tests require the same type of note?

When the test shows changes, the note must reflect that. Additionally, some tests, such as extended ophthalmoscopy (CPT 92225, 92226) and gonioscopy (CPT 92020), can only be performed by the provider. A notation in the medical record is still necessary, but the character of the note is different. For example, extended ophthalmoscopy is usually recorded as a carefully annotated drawing with an interpretation.

Conclusion

Diagnostic tests are a significant part of most practices, so don’t underestimate the importance of a proper “interpretation and report.” Following a test, a cryptic note or single, short sentence isn’t adequate.

As always, “Good coding” to you! OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.