Essentials of Diagnostic Test Documentation – Review of Ophthalmology

Diagnostic tests beyond eye exams: what constitutes an order; the difference between interpretation and report; and more.

This article answers the following questions:

  • Are the ophthalmic diagnostic tests listed in the 2013 Current Procedural Terminology manual treated discretely and separately reimbursed?
  • Does the Center for Medicare Services monitor a physicain’s or group’s practice patterns for billable diagnostic tests?
  • Will an abnormal frequency of a particular test(s) be a red flag for an audit?
  • Who can order a diagnostic test, and what constitutes an order?
  • What is meant by the phrase “interpretation and report” contained in many of the CPT code descriptions for tests?
  • What documentation essentials would constitute an “interpretation” and not just a “review” of a diagnostic test?
  • Where should the interpretation be documented in the patient’s medical record?
  • When does the interpretation and report need to be completed?
  • Are screening tests covered by third-party payers?
  • Are tests reimbursed when performed in the postop period?
  • Are coverage guidelines, e.g., approved diagnosis codes, consistent among Medicare contractors?

This article was published in Review of Ophthalmology’s Medicare Q & A column, which is written by Corcoran’s Vice-President, Donna McCune, CCS-P, COE, CPMA. To view the entire article in Review of Ophthalmology, click on the link below:

See page 20.


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