Medical Decision Making Independent Interpretation

Another term you’ll see within data complexity is independent interpretation. This is the interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified healthcare professional is reporting a service or has previously reported the service for the patient. A form of interpretation should be documented, but need not confirmed to the usual standards of a complete report for the test. And Dr. Cockrell, can you provide us with a few examples of what you would see in an office for an independent interpretation?


Well, the independent interpretation certainly alludes to someone else performing the tests. You’re interpreting the tests post-procedure and not actually performing the procedure yourself.  Your interpretation of a report associated with a test that you’ve performed is being billed as part of that separate CPT code. This is a different set of circumstances where you’re interpreting someone else’s tests and you’re not held to quite the same level of interpretation. But keep in mind, it’s not your tests, it’s someone else’s test.


Thank you. So those will be more than likely you’ll see co-management cases. Would that be an example?


It might, where you’re reviewing an OCT that was performed maybe in a digital retinal specialists office or maybe internal ocular photography performed in someone else’s office and referred to you or maybe even a visual fields was done somewhere else and referred to you for interpretation.