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Wiki documentation issue

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paula f3

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Hello,
We have a ophthalmologist that when he does cataract surgery he does LRI for correction of astigmatism on certain patients. I am aware that this is not a Medicare covered service for an ASC, physician does get an ABN for his office.
My question is his documentation are on template and are the same , it does not state that this procedure was done, should his dictation not state this to indicate that this was done in addition to the cataract surgery?

Paula
 
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