Today’s Take is about independent interpretation, and I know we’ve talked about this before, but I think this is one we’ll have to discuss a lot.
Recently I got a question about this topic from Tracy (Hi Tracy! I’m glad to answer your question.) So, Tracy explained that her providers are pain management providers and included an excerpt from a patient chart (completely PHI redacted), of a lumbar MRI. She also included the actual AMA definition of independent interpretation and wanted to know how many times independent interpretation of that MRI can be counted within the review of each encounter.
When we read the definition of independent interpretation, it states within the definition, “This does not apply when the provider is reporting this service or has previously reported this service for the patient.” Specifically, what they’re cautioning us about here is a provider looking at this image repeatedly and making continuous reassessments of this image with new interpretations. That’s not the expectation here. Again, remember AMA puts certain rules in place to prevent providers from inappropriate actions, knowing that some providers do that -not all, but some providers will do certain actions or create certain work within the documentation of the encounter to show work to drive the level of service.
Remember page 14 of 2023 expansion of 2021 documentation. The work should be appropriate with the complexity of the encounter, and for that reason, you should look at this patient’s presenting problem and consider if it is appropriate based on what the patient is being seen for. Is it appropriate, based on the complexity, that the provider will keep looking at this patient’s MRI? Is there Medical Necessity for what’s being reported? This goes back to our providers continuing to use templates. When providers use templates, and they auto-imported information in the note…that MRI comes into the note or the provider documents that they looked at the image of the MRI, and that MRI is auto-imported, or even the provider puts in their authentic interpretation of that image, we have that in there but why? Why is our provider looking at that image again today?
So many times, people ask me to show them where the rule is that requires the provider has to document this; and so many times, the answer to that question is Medical Necessity. I can’t take you to a rule that says the provider must document “X,Y, and Z”. But what must be documented in the medical record to substantiate the reason that reimbursement should be allowed for this is… Medical Necessity. The reason that the provider must substantiate that reimbursement should be allowed for looking at this MRI visit over visit-over-visit is “why”. You need to explain in the documentation why it would be medically necessary to reassess the images on the MRI every single encounter, and why your interpretation of those images is needed every single encounter -and we would hope it’s not the same interpretation every single time you look at them. That is Medical Necessity. If we have that in the note, we are absolutely justified in allowing that service as Independent Interpretation.
…Real quick, I’ll run a rabbit trail. A question was asked about qualification statements for time, and where in documentation guidelines, it can be found that we must have a statement to substantiate all time; what the time was spent doing or why that amount of time was needed. Medical Necessity. If you’re telling me 45 minutes was spent with a patient with a chest cold or upper respiratory infection, or asthma exacerbation, 45 minutes is a very long amount of time in an office/clinic scenario. We need to know why 45 minutes was required. That’s Medical Necessity. You must validate it. So, with everything you do, you’re looking for medical necessity.
I hope that’s good food for thought. If you have any questions, we are here to help! You might also want to check out our webinars. These are an amazing resource! We also have our weekly Documentation and Compliance tips that are sent by email every Friday. You can sign up to receive audit tips here on our website.
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