Within the Medicare program, ophthalmologists are reimbursed for approximately 1 diagnostic test for each eye exam performed — about 20 million per year. That’s a lot of tests, so it’s not surprising that they are scrutinized for medical necessity and adequate supporting chart documentation. The CPT requirement for an “interpretation and report” can be a stumbling block, particularly when it is not well understood by physicians.

Medicare Regulations and Guidance

The Medicare program guidelines for interpretation of diagnostic tests are discussed in Medicare Claims Process Manual (MCPM) Chapter 13 §100 Interpretation of Diagnostic Tests.¹ CMS differentiates a review of a test from an “interpretation and report.” According to the MCPM, the review of a test is not separately payable, but is included as part of an evaluation and management (E/M) service: “Carriers generally distinguish between an ‘interpretation and report’ of an x-ray or an EKG procedure and a ‘review’ of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which a specialist in the field would prepare, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment.”

Although radiology is mentioned as an example, the regulation in MCPM Chapter 13 §100 applies to other diagnostic testing, such as visual fields and imaging, that also require an “interpretation and report.” CPT codes 92025, 92060, 92081, 92082, 92083, 92100, 92132, 92133, 92134, 92201, 92202, 92235, 92240, and 92250 include the phrase “with interpretation and report.”

CMS continues its discussion of this point, stating, “For example, a notation in the medical records saying ‘fx-tibia’ or ‘EKG-normal’ would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ‘interpretation and report’ should address the findings, relevant clinical issues, and comparative data (when available).” Therefore, when the only notation with an extended visual field is “glaucoma,” this does not satisfy the meaning of the phrase “interpretation and report.” More information is needed.

The Federal Register reinforces this requirement as a condition for payment. The 42 CFR 415.120 (a) states, “(a) Services to beneficiaries. The carrier pays for interpretations only if a written report is prepared for inclusion in the patient’s medical record maintained by the hospital.”² Significantly, without an adequate interpretation, the value of the technical component of the test is unsupported, too.

Writing the Interpretation and Report

An interpretation addresses a number of questions, including the following:

• Why was the test desired?
• When was it performed?
• Who did it?
• Was the test of any value?
• Was the patient at fault?
• What are the results of the test?
• What’s changed from prior test(s)?
• What do the results mean?
• What’s next?
• Who is the physician?

At a minimum, an interpretation of a diagnostic test includes the following:

• An order for the test with medical rationale,
• The date of the test,
• Technician’s initials (very helpful if not absolutely essential),
• The reliability of the test,
• Patient cooperation (especially when it is poor),
• The test findings,
• A comparison with prior tests (if applicable),
• A diagnosis (if possible),
• The impact on treatment and prognosis, and
• The signature of the physician and date.

Here is an example for SCODI of the optic nerve:

• Plan: SCODI-P to re-evaluate POAG
• October 10, 2021
• Mary Smith, COA
• Good image capture
• Good patient cooperation
• RNFL thinning OU
• POAG OU, shows RNFL worsening since last visit
• Add another antiglaucoma medication
• I. C. Better, MD, October 10, 2021

Ideally, the report is isolated and distinct from the chart notes for the eye exam in order to give it prominence and make it obvious. A separate page, a separate entry in EMR, or a separately scanned image is valuable.

There are ophthalmic tests, such as gonioscopy (CPT 92020), that don’t require an “interpretation and report” but do require a separate chart note. Typically, it is a drawing or description of the anterior-chamber angle describing the depth and any abnormalities.

Conclusion

An interpretation does not need to be lengthy, but it must contain more than a single word, such as “abnormal,” or only a diagnosis, such as “glaucoma.” The concept of a report denotes more than a one-word notation. Finally, an interpretation must be timely, meaning that it is completed within a short time of the technical component. The same day is best, the next day is OK, or a few days when a weekend intervenes, but not weeks or months after the test is performed, except in unusual circumstances. A long lag between the testing and interpretation casts doubt on the value of the test to the physician, and it could be potentially injurious to the patient if a serious finding was overlooked and caused harm.

Before a claim can be filed for reimbursement, a diagnostic test must be read by a physician and a diagnosis made. Because the diagnosis cannot be known in advance, a delay in making the interpretation means a delay in filing a claim and receiving payment. A “working diagnosis” probably supports the medical necessity for the test but does not represent a final diagnosis that could be different. Only the ICD-10 code for the final diagnosis belongs on a claim.

With increasing frequency of diagnostic testing by ophthalmologists and optometrists comes added postpayment scrutiny. Missing “interpretation and report” is a common finding by reviewers and auditors and a frequent cause of overpayment determinations. With some attention to the chart, this is readily avoided. GP

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California.

Brandy H. Sperry, COMT, COE, OCS is an associate consultant with Corcoran Consulting Group.

References

1. US Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 13 - radiology services and other diagnostic procedures. Accessed July 1, 2021. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf
2. Office of the Federal Register. 42 CFR 415.120 (a). Accessed July 1, 2021. http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol3/pdf/CFR-2011-title42-vol3-sec415-130.pdf