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Wiki 2023 ED Independent Interpretation Category 2 Question

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jenyb

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We have MDs in an Emergency Department not specifying they personally interpreted X-ray/EKG results in their charts. A few of the coders believe as long as the X-ray/EKG results statement differs from the formal interpretation done by the cardiologist or radiologist qualifies as an interpretation done by the ED MD. I think that the MD needs to specifically state they interpreted the EKG/X-ray in order to count towards Category 2 in the new 2023 ED E/M. Does anyone have any info they can direct me to on this subject? Opinions?
 
jenyb said:
We have MDs in an Emergency Department not specifying they personally interpreted X-ray/EKG results in their charts. A few of the coders believe as long as the X-ray/EKG results statement differs from the formal interpretation done by the cardiologist or radiologist qualifies as an interpretation done by the ED MD. I think that the MD needs to specifically state they interpreted the EKG/X-ray in order to count towards Category 2 in the new 2023 ED E/M. Does anyone have any info they can direct me to on this subject? Opinions?
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It seems that this is an ED prone issue. I see the same thing-
DATA REVIEWED:
"Independent Interpretation of radiology test: CXR appears negative, no consolidation on my review."
It appears to be a template for the ED progress notes. It can be read as an independent interpretation as well as a review of a test ordered.
Sometimes it is being encouraged to be elected as Moderate for data complexity - Independent interpretation
at other times, it is suggested to use it as an order and review.
It would be good to get some clarity on this for sure.
 
I would definitely explain and emphasize to the physician that the CPT guidelines clearly distinguish between a review and an independent interpretation and how this could be the difference between a level 3 vs. 4. Best practice would be for the physician to document along the lines of “Per my independent read of the films” or “I personally interpreted the imaging [findings documented here]*.
 
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