TiffanyM101
Networker
I have a provider that doesn't want to do interps on testing if we arent billing insurance. I dont feel that is correct. Does anyone know where I can find information on documentation guidelines regarding this Thank You
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OCT-A testing
- Thread starter TiffanyM101
- Start date
Edmundo
Contributor
Hi @TiffanyM101 - It's a pleasure!
Even if we are not billing insurance for a diagnostic test, an interpretation and report (I&R) is still required as part of complete and compliant documentation. The CPT descriptor for diagnostic testing includes “with interpretation and report,” which means the service is not fully supported without documented findings and clinical relevance. This is not just a billing requirement—it supports medical necessity, continuity of care, and audit defensibility. Omitting the interpretation can result in an incomplete medical record, even in non-billed scenarios, so best practice is to include at least a brief interpretation for all diagnostic testing performed.
It can be documented within a designated test interpretation section or within the Assessment/Plan, depending on the EMR, as long as it clearly meets interpretation and report (I&R) requirements and is specifically tied to the diagnostic test performed.
Example: “OCT-A: No IRF/SRF. Stable compared to prior. Continue current management.”
Best,
Edmundo Gonzalez, CPC, CRCR, COPC, OCS
Even if we are not billing insurance for a diagnostic test, an interpretation and report (I&R) is still required as part of complete and compliant documentation. The CPT descriptor for diagnostic testing includes “with interpretation and report,” which means the service is not fully supported without documented findings and clinical relevance. This is not just a billing requirement—it supports medical necessity, continuity of care, and audit defensibility. Omitting the interpretation can result in an incomplete medical record, even in non-billed scenarios, so best practice is to include at least a brief interpretation for all diagnostic testing performed.
It can be documented within a designated test interpretation section or within the Assessment/Plan, depending on the EMR, as long as it clearly meets interpretation and report (I&R) requirements and is specifically tied to the diagnostic test performed.
Example: “OCT-A: No IRF/SRF. Stable compared to prior. Continue current management.”
Best,
Edmundo Gonzalez, CPC, CRCR, COPC, OCS