Get Full Credit for Independent Imaging Interpretations
Question: My pediatrician independently reviewed MRI images after the radiologist issued a report. Can that review count toward evaluation and management (E/M) leveling, and if so, what documentation is needed to support independent interpretation? Alabama Subscriber Answer: Yes, a pediatrician’s independent review of MRI images can certainly count toward the data element of medical decision making (MDM) when selecting the E/M level. However, the documentation must clearly show that the physician performed a truly independent interpretation rather than simply repeating the radiologist’s findings. For example, this would be considered insufficient documentation to prove that the pediatrician’s interpretation was independent from the radiologist’s: “MRI reviewed. Findings consistent with radiology report.” This statement does not demonstrate any independent work beyond acknowledging the radiologist’s interpretation. Here is an example of much stronger documentation: “I independently reviewed and interpreted the MRI images of the right knee. My findings are consistent with the radiologist's report of a grade 1 MCL sprain. In addition, I noted mild joint effusion and soft tissue edema surrounding the medial ligament complex, which correlate with the patient’s examination findings and ongoing pain. Treatment options, activity restrictions, and return-to-play considerations were discussed with the patient and their parent.” Make note: The bottom line is that if providers don’t document the work clearly, payers may not acknowledge it. Thorough documentation is critical to ensure independent imaging interpretations are reflected correctly in your E/M leveling. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
