AUG 12, 2024
Documenting the Interpretation and Report
What information must be documented in the interpretation and report of ophthalmic testing?Answer:
The physician is responsible for ensuring that the documentation supports medical necessity per the payer’s requirements for the testing services.
- Note the findings or what was expected or anticipated but not seen. Comment on the status of the patient’s condition. Has it improved, or is it worsening?
- Make a notation of any findings or diagnosis that reveals a need for change in treatment or the impact on patient management