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.