[OneSpot Podcast Resource] Audit-Ready Documentation: Interpretation and Report, Resource 3

p202402 – A Complete Interpretation & Report is NOT Optional

Many of us are not great at documenting a proper interpretation and report (I&R). I&R’s are required for OCTs, fundus photos, visual fields, topographies, ERGs, VEPs, and many more. Special tests that don’t need an I&R are those like pachymetry where the result is a numeric number, and there is not much else that needs to be said. An easy way to find out if a test requires an I&R is to look in the current year’s CPT book. If the description of the code includes the words: “…with interpretation and report,” it requires an I&R. If you look up 92250, it states, “Fundus photography with interpretation and report.” If you look up 92020, it states, just “gonioscopy.” That means you just need to document the findings, but no formal report needs to follow. This has been a rule for decades, yet it is surprising how often I don’t find an I&R documented when doing audits. The reason this is such a big concern is if the I&R is not complete, the test is not billable. The report is just as much of a requirement as the performance of the actual test. In an audit, any payment for a test that is incomplete would be recouped. A visual field with a check mark on it or the letters “WNL” won’t cut it.

The documentation does not need to be a novel, but it must include five things: the Order and the “4R’s.” All testing requires a written order in either the chart on that day or in a previous chart. That means a legitimate order could be found in a prior day’s visit. If a patient presented for her annual exam, and you find suspicion of glaucoma, you could write: “Glaucoma suspect - RTC within 1 month for 24-2, RNFL OCT, pachy, and gonio.” This statement clearly states the tests needed and the reason for them. In other cases, the need for the test is determined and the order is written during the same visit when the test is done.

Once the order has been established, and the test has been performed a complete I&R needs to be documented either in the chart of that day, in a separate I&R document, or directly on the test’s printout. There is no rule that says where the I&R needs to be; you just need one! If the I&R is not directly in the chart, it is best to have a statement like, “I&R on printout.” This would clearly direct an auditor where to find it.

The “4R’s” of an I&R are:

Reason for the test • Reliability of the test • Results of the test • Recommendations based on the results

An I&R does not need to be long or complex. A simple statement such as one of these below is perfectly acceptable. Nothing fancy, just complete. 

These examples certainly take more time to write than just “WNL.” But they take less than a minute. Not only is it required by the payers, it provides better patient care. Imagine getting an MRI that just said, “WNL.” Or one with “defect” and an arrow pointing to something. Your report needs to contain enough info to explain the results and what you are going to do with that information.

Some EHR’s have provided doctors with a false sense of a what an I&R can be. Numerous times I have come across very generic I&R’s that don’t provide any useful information. For example, generic statements like, “OCT performed to monitor and provide progression analysis,” is not helpful. That’s just a definition of what any test is for! Nor is it useful to only state, “RNFL average thickness 78u.” You need to say what the data means…this is the interpretation part. “78u” for the RNFL could mean glaucomatous thinning, or it could mean the patient as peripapillary atrophy and that is just the way they are. You need to “interpret the data.”

Once you get used to the pattern of documentation, an I&R can typically be completed on-the-fly while seeing the patient. Ultimately, another doctor should be able to read just the I&R and understand what test was done, why, what it showed, and what is being done now. They shouldn’t even need to look at the actual test to understand what is happening.