• Evaluation and Management Documentation for Glaucoma Suspect


    A patient is a glaucoma suspect and has chronic dry eyes. The visual fields ordered and performed were suspicious for disease progression. The plan is for patient to follow up in 1-2 months with repeat visual field. What level evaluation and management (E/M) does the documentation support?

    Looking at the E/M table for medical decision-making, the patient presented with two or more stable chronic illnesses meeting the moderate level. The ordered visual field does not meet moderate amount of data, any test with a CPT code current or past for which you receive/received separate payment does not count in this category. The plan does not meet moderate risk having no prescription drug management. This would be a 99203/99213. Formal training for E/M documentation can be found at Conquering New E/M Documentation Guidelines for Ophthalmology (aao.org)
    Frequency edits apply to visual fields. You should not bill for a test that does not give data needed to treat the patient.