Wiki Independently Interpreted/Independently Reviewed

[lauraleerdh]

Hello,
I am tangled up with , if Independently Interpreted and Independently Reviewed are the same thing.

In Practicode, there have been cases where the ER provider stated he independently reviewed a test, lets say an xray.
I didn't count it towards the MDM and was wrong (in the end the level I calculated was a step lower than the answer key), the rationale indicated in the counting towards MDM was the Independent interpretaiton.
When I inquired as the why I was wrong, the reply was that the ER provider Independently Reviewed the xray, therefore "Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)" should be counted as an independent review of the xray was him giving an independent interpretation.

In another Practicode case, same situation, ER providers tated he independently reviewed an xray. I counted that towards the MDM, answer key was an EM code one down from my answer, and the rationale didn't state Independent interpretation was counted toward the MDM.
I inquired as to why independent interpretation wasn't counted , was told that 'independently review' of a test isn't counted because it doesn't state the provider gave his own interpretation -- their assessment was he just looked at it.

So, same situation, oppositive results.

My question to the fine people on this forum, is Independently Reviewed the same as Independently Interpreted the same thing or isn't it?
How would you all assess this in a case you had?

Thank you

 

[sls314]

Hello,
I am tangled up with , if Independently Interpreted and Independently Reviewed are the same thing.

In Practicode, there have been cases where the ER provider stated he independently reviewed a test, lets say an xray.
I didn't count it towards the MDM and was wrong (in the end the level I calculated was a step lower than the answer key), the rationale indicated in the counting towards MDM was the Independent interpretaiton.
When I inquired as the why I was wrong, the reply was that the ER provider Independently Reviewed the xray, therefore "Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)" should be counted as an independent review of the xray was him giving an independent interpretation.

In another Practicode case, same situation, ER providers tated he independently reviewed an xray. I counted that towards the MDM, answer key was an EM code one down from my answer, and the rationale didn't state Independent interpretation was counted toward the MDM.
I inquired as to why independent interpretation wasn't counted , was told that 'independently review' of a test isn't counted because it doesn't state the provider gave his own interpretation -- their assessment was he just looked at it.

So, same situation, oppositive results.

My question to the fine people on this forum, is Independently Reviewed the same as Independently Interpreted the same thing or isn't it?
How would you all assess this in a case you had?

Thank you

Independently interpretation of an x-ray would mean that the physician reviewed the actual images and came up with their own reading/interpretation. The physician's findings should be clearly documented in the note.

A review would mean the physician looked at the radiologist's written interpretation and report. The physician was not making their own interpretation of the images and documenting their own findings.

 

[lauraleerdh]

Independently interpretation of an x-ray would mean that the physician reviewed the actual images and came up with their own reading/interpretation. The physician's findings should be clearly documented in the note.

A review would mean the physician looked at the radiologist's written interpretation and report. The physician was not making their own interpretation of the images and documenting their own findings.

Thank you Susan, that is what I felt the meanings were. But I am being told from one of the Practicode coaches that "Independently Reviewed" is that the ER physician is viewing the images and interpreting them.

My argument is, the documentation does not state 'interpreted' only 'reviewed" and wanted to be sure the terms "independently reviewed" and "independently interpreted" weren't interchangable base on the 'independently"

I wanted to be sure I was correct in my assessment of the definitions of the two as I don't want to make a dumb error in 'real world' coding.

Thank you again for your time

 

[csperoni]

I certainly can't advise about Practicode cases or instructions. I agree with @sls314 the difference is whether the ER physician looked at the images and drew a conclusion or looked at the radiologist's report. The nuance is in the wording of the medical record to determine which was done. Regardless of whether or not the word "interpretation" was used.
For example:
I reviewed the chest xray images from this evening and determined there is a small area of concern in the left upper lobe 2.2cm x 3.1cm. Will correlate with radiologist report. Will refer to pulmonology for further evaluation.
The record doesn't say "I interpreted the xray.", but clearly meets the definition for independent interpretation.
To count independent interpretation, it needs to be clear that the IMAGES were looked at and interpreted. If I see documentation stating "I reviewed the chest xray. Finding of small area of concern in the left upper lobe 2.2cm x 3.1cm.", I simply do not know if that physician looked at the images and came to that conclusion or read the report and is reiterating the radiologist's finding. I would not count independent interpretation in that wording, and would educate the physician about clearer documentation IF/WHEN they are reading images.