Optometry Coding & Billing Alert
Figure Diagnostic Decision Into E/M Level
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Question: A new patient reports with blurred vision and a severe headache. During the course of an E/M service, the doctor prescribes pain medication for the patient. The OD recommends the patient undergo a visual field test to further investigate the issue. If the patient never actually gets the recommended test, should the optometrist get credit for the field test order when deciding the E/M level? Iowa Subscriber Answer: You can factor your order into the medical decision-making -- but make sure you document-that you ordered the test. Also, factor your decision to run a visual field test into your E/M level, because you made a medical decision to run the test -- even if the patient ultimately decides against the service. Suppose the notes indicate that you provided a level-three service to the patient. On the claim, report the following codes: - 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision-making of low complexity) for the E/M - 784.0 (Headache) linked to 99203 to represent the patient's headache - 368.8 (Other specified visual disturbances) linked to 99203 to represent the patient's blurred vision.
Optometry Coding & Billing Alert
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