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Ophthalmology and Optometry Coding Alert

You Be the Coder:

Differentiate Between QHPs and Staff for Definitive Documentation

Published on Tue Dec 20, 2022

Question: There are times when a patient says something to ancillary staff, but there’s no mention of the issue in the ophthalmologist’s documentation. If a patient tells the medical assistant who rooms them that they are experiencing excessive tearing in both eyes, but the physician does not include epiphora in their note, can we as coders denote H04.213 as one [...]
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