Ophthalmology and Optometry Coding Alert

Reader Questions:

Maintain Lab and Diagnostic Test Orders

Question: Our insurer wants to audit our test orders — what does this mean?

Georgia Subscriber

Answer: In addition to documenting diagnosis and procedure codes thoroughly, remember to record the orders and results for diagnostic testing, as well as interpretations and reports, when applicable.

Some payers are performing audits on diagnostic testing. All of those diagnostic tests require some level of interpretation and report. Unfortunately, just pulling the data in from those tests does not constitute an interpretation and report, those are just the results. Always keep a copy of every order in the patient’s medical record.