The latest Medicare eNews email blast from Wisconsin Physician Service (WPS) Government Health Administrators, the Medicare administrative contractor (MAC) for Iowa, Kansas, Missouri, Nebraska, Indiana and Michigan, included the statement and link below relating to diagnostic services:
The Comprehensive Error Rate Testing (CERT) contractor continues to assess errors due to the lack of a physician order and/or clinical documentation to support medical necessity for diagnostic services. See Diagnostic Services-Documentation Requirements for examples of these errors, reminders, and resources.

Recent external audits performed by the Academy’s Coding Consultants confirm these findings from the Centers for Medicare & Medicaid Services (CMS). Top deficiencies include:  

• Missing order with specific test including which eye(s)
• Lack of interpretation and report with the physician’s signature or initials and date
• Inappropriate diagnosis link to establish medical necessity

The Academy has multiple resources outlining the documentation requirements and to help you be prepared for any audit: 

Back to the Basics: Testing Services, Part 1

Back to the Basics: Testing Services, Part 2

Back to the Basics: Testing Services, Part 3

Required Information for Testing Services 

Audits

2023 Fundamentals of Ophthalmic Coding

For a comprehensive review of all your chart documentation and to solve any of your coding and practice management challenges, schedule an appointment with academy experts: 

Schedule Coding and Practice Management Consultations for Ophthalmology