What is an Interpretation and Report? When do you need one?
An
Interpretation and Report is required documentation for certain
(usually imaging) procedures.
These reports are not optional!
Insurance payers
consider the report a major part of the procedure which is being
reimbursed.
However, most doctors are not in compliance with this
requirement.
In fact we have found that 80% of doctors do not complete a report or do not complete the report properly.
In addition to the requirement of creating a report, there are specific requirements for the contents of the report. One major point of confusion is the requirement, where the Interpretation and Report is "a separate report (electronic or paper) not part of the exam record."
The contents of the report are also referred to as “The 3 C’s.”
Clinical Findings - What did you do. What did you find. Was it a reliable study.
Comparative Data (Change in Condition) - Is the patient better, worse, or the same.
Clinical Management - Document the affect this test will have on the patient's Clinical Management.
What happens if I do not do an Interpretation and Report?
If a payer requests a copy of a report and it was not done, the payer can audit your practice. They will look at all procedures requiring an Interpretation and Report. For those not completed you must re-pay; the full Reimbursement plus Penalties plus Interest! We have seen across the country, where this has added up to $100,000 per doctor!
Bottom line: Do your Interpretation and Reports!
EyeCOR Provides you with a Interpretation and Report
EyeCOR has a built in Interpretation and Report system. You can quickly create a report. The report has all the required elements and warns you if it is not fully completed.
The report has pre-written text specific to the procedure and the category. Just a few clicks and you are done.
The EyeCOR Interpretation and Report protects you from an audit by:
Identifying all procedures requiring an Interpretation and Report
Providing you with an Interpretation and Report form
Pre-written text allowing quick and easy documentation
Learn your terminology by allowing you to add or modify the pre-written text
Providing you Medical - Legal protection by:
Protecting the saved report.
Giving you the ability of creating addendums date and time stamped
Either or both
Printing the report for inclusion in your charts
Saving the report electronically