Wiki "CXR Looks Good" - 1 point or 2?

[SUEV]

My provider looked at the chest x-ray image but only documented "CXR looks good". Would you give 1 point for review of Radiology test or would 2 points be ok since he used the word "look", implying

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independent review of the image?

Thanks,
Sue​

 

[CodingKing]

Looks good can be interpreted many ways but i think most would interpret that as nothing abnormal in the x-ray report. For example Noridian states:

The medical record documentation must clearly indicate that the physician/qualified NPP personally(independently) visualized and performed the interpretation of the image; tracing or specimen and that he/she did not simply read/review a report from another physician/qualified NPP.

 

[SUEV]

Thanks! I would expect to see a little more detail in an independent review and we ask that providers specify when they're looking at an image. The problem is that 1 point is the difference between Moderate and High MDM for this particular audit so I like to see if I'm in the majority when it comes to interpreting ambiguous phrasing

 

[thomas7331]

The wording regarding this element of MDM in the 1995 guidelines is that "direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented." I would interpret this to mean that in order to have a documented "independent interpretation", there needs to be a summary of the providers findings from the direct visualization. So I would give only one point for "CXR Looks Good" as it doesn't provide any record of what was seen.