I’ve written many columns recently about the coding of diagnostic tests, with answers on:
  • Whether a test is considered unilateral or bilateral. (It depends on the test.)

  • Whether it can be done on the same day as any ophthalmic or E/M office visit. (Yes, it can.)

  • Whether it is subject to the new Multiple Procedure Payment Reduction rule that came into place on January 1 of this year. (They all are.)
But these questions, and others, about how the test is carried out is only half of the story of diagnostic testing.

What’s the other half of the story? The second essential part is the interpretation and report (I&R) that must be done to properly meet the requirements for performing a diagnostic test.

The CPT clearly defines that, “Interpretation and report by the physician is an integral part of the special ophthalmological services where indicated and that the technical procedures (which may or may not be performed personally by the physician) are often part of the service, but should not be mistaken to constitute the service itself.”

What does that mean? It means that, by definition, the test is not deemed to be completed until the interpretation and report has been finished. Bear in mind that the term “interpretation and report” means just that. You must interpret the results of the test—and report on how the test affected the care plan for the patient.

Clearing Misconceptions
Before getting into the specific components of the I&R, let’s talk about a couple common misperceptions surrounding it. Some lecturers have said from the podium that the I&R must be done in a “special report format” or “on a separate piece of paper.”

I disagree; I have yet to find a CMS reference or any other supporting evidence for this. From my research, an I&R needs to be clearly identified within your medical record for the specific test it is associated with. That is, each test that you perform requires its own I&R—no exceptions. But, as long as the technical test findings and the I&R for that specific test are clearly associated with each other, you should be fine in an audit without the need for a special format or separate piece of paper.
 
Remember, each diagnostic test you order and perform must have proper medical necessity established for it in the medical record if a third-party carrier is going to pay for it. If you have a specific reason for which you believe that a test may be denied, then use an advance beneficiary notice (ABN) and the appropriate modifier accordingly.

What the I&R Includes
Here are the typical items that you should include in an I&R:
  • Clinical findings, which is the pertinent data of the test results.

  • Your interpretation of those findings.

  • Comparative data to previous test results (if applicable).

  • Clinical management, which explains how the test results will affect the management of the condition/disease going forward. Examples include:
    •  Change/increase/stop medication
    •  Recommendation for surgery
    •  Recommendation for further diagnostic testing
    • Referral to a specialist/sub-specialist for additional treatment
    • Returning to you for additional office visits for monitoring and/or treatment
Simply performing the technical component of the test is not enough; nor is simply initialing the test to show that you’ve looked at it. When a carrier finds that an I&R hasn’t been completed, then the entire test is deemed to be invalid; this means that you’ll have to return the entire payment to the carrier, not just the amount for the professional component of the test.

Diagnostic testing is becoming more common in our practices. Advancements in patient care depend on our ability to properly perform diagnostic testing properly. So, fulfilling the diagnostic test requirements by appropriately completing an I&R for each test performed will not only benefit your patient, but will also reduce your risk.