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  • Interpretation and Report

    Do I have to create a separate interpretation for OCT-RNFL or may I state “see OCT” in my plan?

    From the Academy’s book 2022 Fundamentals of Ophthalmic Coding:
    “The interpretation and report do not require a separate dictated report. It can be written on the test, or in the medical record or on a testing flow sheet. It must be made available to any payer upon request. It is the responsibility of each physician to document the interpretations as promptly as possible and then communicate the findings with the patient. Work with the technicians and ophthalmic photographers to develop a fail-safe way to ensure that your interpretations are completed in a timely manner.”

    What auditors are looking for:
    For any tests delegated to ancillary staff, you need to document an order in the chart. It should indicate:
    1. the test(s) to be performed
    2. in which eye(s)
    3. the medical necessity
    The physician should also provide the interpretation and report. If the physician performs the test, this should be easily inferred along with the findings. Document them in the chart notes.