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Interpret and report – Ophthalmic Professional

I am often asked, “How much is enough?” to document when a diagnostic test has the words “with interpretation and report” in the code descriptor.

Because diagnostic testing accompanies almost every eye exam and insufficient chart documentation is reason enough to require repayment, it’s a good question. Although not all diagnostic eye tests require this extra step, most that result in a charge do.

This article addresses the following topics regarding interpretation and report:

  • Medicare regulations
  • Where and when to write it
  • CPT codes that require an interpretation and report
  • Payment considerations
  • Do all tests require the same type of note?

This article was published in Ophthalmic Professional’s Coding column, and written by Corcoran’s Senior Consultant, Paul Larson, COE. To

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