Codapedia is now a division of Find-A-Code

HCC - Acceptable Provider Interpretation for Diagnostic Testing

October 1st, 2018 - Wyn Staheli, Director of Research
Categories:   Reimbursement   Cardiology|Vascular   Surgical Billing & Coding   Billing   Diagnosis Coding   Diagnostic Testing  
0 Votes - Sign in to vote or comment.

The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing.

Diagnostic Testing (with or without interventional procedures)

with acceptable provider interpretation

Explanation/Examples

Acceptable Examples include:

  • Cardiology and Vascular Surgeons
  • Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels)
  • EKG (electrocardiogram) – Stress test, Cardiac catheterization ◦ Myocardial perfusion and other nuclear medicine imaging of the heart
  • Pacemaker analysis (non-telephonic)
  • Vascular Doppler Study interpretation- not performed by Diagnostic Radiologists
  • Percutaneous transluminal coronary angiography (PTCA) Interventional Radiology
  • Catheter angiography – Coronary Computed tomography angiography (CTA)
  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Embolization procedures
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Magnetic resonance arteriogram (MRA)
  • Fluoroscopic Guidance
  • Genitourinary vascular flow imaging (nuclear medicine)
  • Radiofrequency ablation
  • Radiation Therapy – Ultrasound Guidance Neurology
  • Electroencephalography (EEG)
  • Electromyography (EMG)
  • Nerve Conduction Studies
  • Nuclear Medicine Brain imaging
  • Sleep Studies (Polysomnography) Pulmonology
  • Pulmonary Function Tests (PFT) Pulmonary perfusion and ventilation imaging

Reviewer Guidance

Reviewers should only submit diagnoses documented in the physician interpretation, not the technical report. Do not submit records of diagnostic radiologist only.

Standalone/outpatient/physician encounters:

If an exact diagnosis is not reported, and the record is identified as outpatient, apply outpatient coding guidelines to code the condition to the level of certainty documented. Often the reason for the test is listed as symptom or abnormal findings on another test. If the reason for the test is to rule out a diagnosis, do not report the diagnosis if the exam is normal or does not indicate the rule out diagnosis. The reviewer must use judgment based on the type of procedure/test or other documentation available when determining if a chief complaint or reason for a test is a current diagnosis or was a condition to be ruled out.

Example:

MRA, reason for test: non-healing ulcer. MRA studies rule out vascular or heart disease, not ulcers. The ulcer would be reported as a current condition along with any abnormal findings of the study.

Interpreted diagnostic testing within inpatient records: See guidance for Other Physician Documentation. Generally, interpretations from acceptable provider specialties are acceptable as long as there is no contradiction with the attending physician diagnosis.

Diagnoses documented in EKGs, MRA, Doppler studies, and other testing must be addressed by the attending physician or consulting provider to submit for condition validation.

 RADV Auditor Action

Researched on a case-by-case basis to determine if study is performed by a Diagnostic Radiologist or a valid physician specialist, such as Vascular Surgeon or Cardiologist.

Stand-alone/outpatient EKG interpretations are considered for reporting on a case-by-case basis.

The cardiologist signature must be present and the results supported in the clinical notes.

Findings are often “suggestive of” and not confirmed diagnoses. This is especially true for “Old MI (myocardial Infarction)” findings since false positive findings are not uncommon.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019 - Wyn Staheli, Director of Research
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
Charging Missed Appointment Fees for Medicare Patients
February 7th, 2019 - Wyn Staheli, Director of Research
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
Q/A: Do Digital X-rays Have Their Own Codes?
February 7th, 2019 - Wyn Staheli, Director of Research
Question Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes? Answer There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
Clinical Staff vs Healthcare Professional
February 5th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.  Physician or other qualified healthcare professionals:  Must have a State license, education training showing qualifications as well as facility privileges.  Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...
BC Advantage Now Offering Q-Pro CEUs!
February 5th, 2019 - Find-A-Code
We are excited to announce BC Advantage is now offering Q-Pro CEUs! It is now even easier to get your QPro CEUs and stay current with BC Advantage: offering news, CEUs, webinars and more. BC Advantage is the largest independent resource provider in the industry for Medical Coders, Medical Billers,...
Attestations Teaching Physicians vs Split Shared Visits
February 1st, 2019 - BC Advantage
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
Q/A: Can I Bill a Review of X-Rays?
February 1st, 2019 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...



About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association