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:

http://bt.e-ditionsbyfry.com/publication/?i=169792

See page 20.