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foreign [Music] we're talking independent interpretation hi Shannon deconda with nemus and today's take is about independent interpretation and I know we've talked about this before but I think this is when we're gonna have to talk about a lot um recently I got another question about this topic from Tracy hi Tracy glad to answer your question today so Tracy's question she's submitted to me an excerpt from a patient chart completely Phi redacted and it was a lumbar MRI and her question was when it comes to the actual definition that ama has in the 2021 documentation guidelines she re put in the definition from the guidelines as to Independent interpretation our providers are pain management providers our patients come in and our providers are reviewing the MRI with the patient how many times can independent interpretation of that MRI be counted within the review of each encounter because when we read the definition of independent interpretation it states within the definition this does not apply when the provider is reporting this service or has previously reported this service for the patient specifically what they're cautioning is this is not supposed to be that the provider is looking at this image over and over and making continuous reassessments of this image with new interpretations that's not the expectation here again remember AMA put certain rules in place to prevent providers from inappropriate actions knowing that some providers do that not all but some providers will do certain actions or create certain work within the documentation of the encounter to show that work there in order to drive the level of service remember page 14 of 2023 expansion of 2021 documentation the work should be appropriate with the complexity of the encounter and for that reason what we're going to do is look at this patients presenting problem and say would it be appropriate based on what the patient is here for is it appropriate based on the complexity that the provider is going to keep looking at this patient's MRI is their medical necessity for what's being reported again this goes back to Providers continuing to use templates when providers use templates and they use Auto imported information into the note that MRI comes into the note or the provider documents that they looked at the image of the MRI and that MRI is auto imported or even that provider puts in their authentic interpretation of that image and we have that in there but why why is our provider looking at that image again today so many times people send me questions and they say show me where the rule is that requires that the provider has to document this and so many times the answer to that question is medical necessity I can't take you to a rule that says the provider must document x y and z but what I must have in the medical record to substantiate the reason that reimbursement should be it should be allowed for this is medical necessity so the reason that the provider must substantiate that reimbursement should be allowed for looking at this MRI visit over visit over visit is why you need to explain in the documentation why it would be medically necessary to reassess the images on the MRI every single encounter and why your interpretation of those images are needed every single encounter and we would hope that it's not the same interpretation every single time you look at them that is medical necessity and if we have that in the note then we're absolutely Justified and allowing that service as independent interpretation I hope that's good food for thought so with everything you do you're looking for medical necessity so real quick I'll run that Rabbit Trail I know we're at the five minute mark but the question was asked what about qualification statements for time show me where in documentation guidelines it says I must have a statement to substantiate time what the time was spent doing or why that amount of time was needed medical necessity if you're telling me 45 minutes was spent with a patient that had a chest cold or upper respiratory infection or asthma exacerbation 45 minutes is a very long amount of time an office Clinic scenario we need to know why 45 minutes was required that's medical necessity you have to validate it and I think we can wrap up with that today find us here we are able to answer your questions and help you check out our webinars check out the next audit tip coming your way you can sign up for our audit tips right on our website hope to see you here again soon thanks and have an amazing day