By Mary LeGrand, RN, MA, CCS-P CPC, and Margi Maley, BSN, MS

Is a separate report necessary?

Our physicians understand the need to dictate a report for the professional interpretation of an X-ray, but they question whether the report must be separate from the evaluation and management (E/M) note. Can you clarify this for us?

This question is asked regularly. In February 2007, AAOS Now addressed the issue in the article “Do professional interpretations of X-rays require a written report?” When the question came up again in December 2008, we researched whether any changes had been implemented since the 2007 article.

In 2008, the definitions and instructions related to “Reports” were revised beyond the instructions found within the radiology and E/M sections of the American Medical Association (AMA) Current Procedure Terminology (CPT) Manual. The following three citations/guideline instructions are found in the 2009 AMA CPT Manual:

• Results are the technical component of a service. Testing leads to results; results lead to interpretation. Reports are the work product of the interpretation of test results. Certain procedures or services described in the CPT codebook involve a technical component (eg, tests), which produce results (eg, data, images, slides). For clinical use, some of these results require interpretation. Some CPT descriptors specifically require interpretation and reporting to report that code. (2009 AMA CPT, p. xvi)
• The physician’s interpretation of the results of diagnostic tests with preparation of a separate distinctly identifiable signed written report may also be reported separately from the technical component of that service, using the appropriate CPT code with the modifier “26” appended. (2009 AMA CPT, p. 3)
• A written report, signed by the interpreting physician, should be considered an integral part of a radiology procedure or interpretation. (2009 AMA CPT, p. 302)

Other supporting evidence
According to Medicare’s Claims Processing Manual (Chapter 13, Rev. 1472 [03-06-08], Section 100.1), “carriers generally distinguish between an ‘interpretation and report’ of an X-ray or an EKG procedure and a ‘review’ of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the … evaluation and management (E/M) payment. For example, a notation in the medical records saying ‘fx-tibia’ or ‘EKG-normal’ would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ‘interpretation and report’ should address the findings, relevant clinical issues, and comparative data (when available).”

The search for rules that support the possibility of including the imaging report within the body of the E/M note also uncovered a Medicare carrier’s policy. Trailblazer is a Medicare carrier that processes claims in Colorado, New Mexico, Oklahoma, and Texas, and for Indian Health. The November 2008 Trailblazer Medicare Publication addresses supporting a report within the body of the E/M with explicit documentation requirements.

Trailblazer says their response was the result of continued physician inquiries about the requirement for a separate report or the appropriateness of including the report within the body of the E/M note. Their revised policy follows and applies only to physicians and healthcare providers covered under Trailblazer Medicare:

Diagnostic Radiology Pub. 11/08 31

Written Interpretation and Report Documentation

Based on the increased number of provider questions regarding written interpretation and report of diagnostic X-rays, Medicare expects the separate and distinct report (may be on separate paper or within the body of the patient’s record) for the interpretations to follow the American College of Radiology (ACR) guidelines and include a minimum of the following:

• The name of the patient and other identification such as birth date and Social Security number
• The name of referring physician, if any
• The name or type of examination performed
• The date on which the X-ray was performed
• The name of the interpreting physician
• Authentication of non-handwritten note (ie, legible initials, legible signature, electronic signature, etc)

The body of the report:

• Procedures and materials
• Findings. Limitations. Clinical issues.
• Comparative data, if indicated
• The diagnosis
• A prescribing diagnosis should be provided when possible.
• A differential diagnosis should be provided when appropriate.

Supportive documentation was not found on the Web sites of Wisconsin Physician Services, Noridian, NHIC, First Coast, Palmetto, or HGSA, which were reviewed in December 2008.

Recommended action steps
Continue to dictate a separate report when reporting the global radiology codes (no modifier) or professional interpretation (with modifier 26) to all payors except Trailblazer Medicare. In the case of Trailblazer Medicare, follow their requirements.

Create a dictation template to include the requirements necessary to support reporting the professional interpretation and to meet the reporting guidelines for your carrier.

If you are not covered by Trailblazer Medicare, contact your local carrier asking for similar guideline instructions.

Contact private payors in writing to determine if they will accept a report within a separate heading in the E/M and/or surgical note.

Physicians should pay attention to this issue as the consequences of cavalier behavior include the request for a large, expensive refund as part of a Medicare Recovery Audit. The number of recovery audit contractors is growing, and this will likely lead to more audits.

Mary LeGrand, RN, MA, CCS-P, CPC, and Margi Maley, BSN, MS, are consultants with Karen Zupko & Associates. The information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org