Personal interpretation of radiology test during an E/M

Q:

Are there documentation suggestions for a provider’s personal interpretation of an x-ray under the new E/M guidelines when awaiting the radiologist’s formal read? 

A:

This a great question and a topic that requires unambiguous documentation. Otherwise, it may read as though the information was taken from the radiology report or as though the global radiology service was performed. To avoid confusion, we recommend statements that identify the ordered service and the clinician’s interpretation.  Consider the following examples: 

“X-ray reveals _______, will await radiologist overread.”

“X-rays ordered, radiology overread pending.  To my interpretation,  ….”

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