Understanding Independent Interpretation in E/M Coding:
Three Essential Requirements
Shannon O. DeConda, CPC, CPMA, CEMA, CPA-EDU
October 4, 2024
In the realm of Evaluation and Management (E/M) coding, independent interpretation is an often misunderstood component of the Medical Decision Making (MDM) table. Proper documentation of independent interpretation is required to impact the MDM and, consequently, reimbursement. Let’s break down Independent Interpretation into three essential requirements to ensure compliance and appropriate coding:
- Personal Review of the Test
- Documentation of the Provider’s Own Interpretation
- Demonstration of Impact on Patient Care Based on AMA’s Definition of “Analyzed”
1. Personal Review of the Test
The term “independent” in independent interpretation underscores the necessity for the provider to personally review the diagnostic test—be it a specimen, imaging, or tracing. This means the provider must go beyond reading the radiologist’s or pathologist’s report; they need to examine the actual images, slides, or tracings themselves.
Why This Matters: Relying solely on another professional’s report does not meet the criteria for independent interpretation. Personal review would be performed when a provider needs this personal review to best make informed decisions based on firsthand analysis, which may reveal nuances not captured in the initial report.
Example: A primary care physician personally reviews a patient’s chest X-ray images to assess subtle signs of pneumonia that were not highlighted in the radiologist’s report.
2. Documentation of the Provider’s Own Interpretation
After personally reviewing the test, the provider must document their own interpretation in the patient’s medical record. This documentation should be a clear, concise analysis that reflects the provider’s findings from their review.
Best practices for documentation to ensure the key elements are addressed would be to include:
- Findings: Specific observations noted during the review.
- Assessment: The provider’s professional judgment regarding these findings.
- Conclusion: How these findings influence the patient’s diagnosis or treatment plan.
Why This Matters: Proper documentation serves as evidence that the provider performed an independent interpretation, which is necessary for coding and billing purposes. It also enhances the continuity of care by providing detailed insights into the patient’s condition.
Example: The physician notes, “Upon reviewing the chest X-ray, there is evidence of a small infiltrate in the lower left lobe consistent with early pneumonia.”
3. Demonstration of Impact on Patient Care Based on AMA’s Definition of “Analyzed”
The American Medical Association (AMA) emphasizes the importance of how any reviewed data is “analyzed” and how it impacts clinical decision-making. According to the AMA, for data to be considered analyzed, the provider must demonstrate how it impacted the episode of care. In this instance how their independent interpretation influenced the patient’s episode of care.
Recommended best practices for documentation include:
- Clinical Relevance: Explain how the findings affect the patient’s condition.
- Treatment Decisions: Detail any changes or confirmations in the treatment plan based on the interpretation.
- Patient Outcomes: Highlight potential implications for the patient’s health outcomes.
Why This Matters: Simply reviewing and documenting findings is insufficient to establish the medical necessity for re-reviewing a previously interpreted test. The documentation should clearly demonstrate how the provider’s independent review adds value and impacts the patient’s care, showing that the second review was essential for clinical decision-making. This connection validates the necessity of the independent interpretation and fulfills coding requirements.
Independent Interpretation in the Inpatient Setting
Encounters in the inpatient setting are particularly vulnerable to errors related to independent interpretation. Providers often have daily access to imaging and other diagnostic tests, which can lead to the mistaken belief that re-reviewing previously interpreted tests automatically adds value. However, it is important to remember that the availability of test results does not inherently make it medically necessary to perform a second review. For the re-evaluation to qualify as independent interpretation, the provider must document how this additional review impacted the patient’s treatment or clinical course. Without such justification, the second review may fail to meet the criteria for independent interpretation, leading to potential coding errors and denials.
Why This Matters: Inpatient settings involve complex and dynamic patient conditions where multiple tests are frequently ordered. Providers must discern which additional reviews are clinically justified to avoid unnecessary documentation and potential compliance issues.
Educating Physician on Best Practices for Documentation
To ensure all key elements are addressed in documentation, consider the following key points to educate your providers for implementing the following best practices:
- Detailed Notes: Provide comprehensive notes that capture the provider’s review process and findings.
- Clear Language: Use unambiguous language to describe interpretations and their implications for patient care.
- Timely Updates: Update the medical record promptly after reviewing and interpreting test results to maintain accuracy.
- Cross-Verification: When applicable, cross-verify findings with other diagnostic information to support clinical decisions.
- Use of Templates: Utilize standardized documentation templates to ensure consistency and completeness in recording independent interpretations.
By integrating these best practices, providers can further strengthen their documentation, supporting compliance with coding requirements.
About Ms. DeConda:
Ms. DeConda has spent her entire career in healthcare. She started as a check-in receptionist and worked her way through respiratory therapy school. She has worked in various roles in healthcare including medical assisting, respiratory therapy, practice management, billing and denials support, practice liaison, and in-office practice coding, auditing, and educating.
Ms. DeConda established NAMAS, the National Alliance of Medical Auditing Professionals in 2007. It was the first organization to formally educate and certify medical auditors. Today, she is the president of NAMAS, which is a division of DoctorsManagement. Ms. DeConda has been with DoctorsManagement since 2005 and is an Equity Stakeholder in the company.
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