by Stephanie Allard , CPC, CEMA, RHIT
March 21st, 2022
When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was completed on that date and personally interpreted by the rendering provider supporting a separately billable x-ray service. Second, we must review documentation to be able to tell whether the provider reviewed an external x-ray report of another provider to be counted towards an element of Medical Decision Making (MDM). Third, if there was an external x-ray was discussed and the note does not show the review of another provider’s x-ray report we must review documentation for support of a personal interpretation of the external x-ray image, which also would be counted towards an element of MDM for an E/M service.
There are many scenarios that can make the audit of an x-ray, as mentioned above, difficult to decipher. I have personally found that when the documentation is not clearly supporting what the provider would like to bill or how they would like the work credited towards MDM it is due to the templates within their EMR system, use of the EMR system, and/or the documentation is lacking the required detail.
During my audits, I have seen that when it comes to the EMR system something as simple as the heading for the x-ray section within the E/M note does not contain the information that providers are counting on to support the work they have performed. For example, the heading of “X-ray Results” does not give an auditor the level of detail needed to determine whether the x-ray was completed on that date or whether an external x-ray was reviewed or personally interpreted.
In my own reviews, I have seen that lack of documentation from the rendering provider has been the larger issue. When information throughout different sections of a note is having to be pieced together and only supports an external interpretation or performance of an x-ray based on an assumption, the x-ray will not be supported in the way that the provider intends to be credited for the work. For example, when an x-ray order is entered into the EMR order module on the same date as the E/M without documentation of the order or the intent to order in the Assessment & Plan an auditor should not assume that the documentation listed under “X-ray Results” was the interpretation for x-rays completed on that date.
An x-ray interpretation is not just a restatement of the order with a final impression. It instead must be a report of findings that mirrors a report that would be completed by a specialist in the field. An interpretation report must show the structures reviewed with both the normal and abnormal findings documented and should also include relevant clinical issues and comparative data, when available.
When it comes to billing for x-rays that were completed on the same date as an E/M the interpretation can be documented within the E/M encounter note, but the note must clearly identify the order, completion of the x-ray on that date and the personal interpretation by the rendering provider.
- The number and/or name of views taken
- The anatomic location of the x-ray, including laterality
- A diagnosis/indication for taking the x-ray(s), including laterality
- An interpretation of the x-rays, including the details of the structures reviewed and findings
- Final impression
In order to receive credit for the work that goes into an external x-ray, the documentation must show the source of the external x-ray, the anatomic location of the x-ray and then further identify whether the provider is personally interpreting an external image or if the provider is reviewing the x-ray interpretation report from another provider. If the external image is interpreted the note must identify that so that the documentation is not mistaken for a review which could impact the level of service supported. The note must also include the provider’s documentation of their personal interpretation of the external image.
As with everything that we review as auditors it is important to take a step back and make sure that we review the details of the documentation and not just the known intent of the provider. This can become difficult for internal auditors/coders who are comfortable with the provider’s workflow in the practice and know what is typically done. Remember an x-ray interpretation should be able to be “carved out” of the E/M documentation and support the service as a stand-alone report.