Wiki Ophthalmology E&M coding/HELP

[cynthiar]

Anyone out there working in an Ophthalmology practice, I am doing chart reviews and have the Eye exam 97 guidelines. My question, several of the exam bullets say " Slit lamp examination", if the physician uses a penlight exam instead of a slit lamp, can I still count that particular bullet?
Any help would be appreciated, I am having sooo much trouble just reading the physician's handwriting, but I do not want to short change him on these 3 bullets.
Thanks
Cynthia Robinson:

 

[Barbara Burgess]

Most definitely not ! A slit-lamp exam is a specialized eye exam and the doctor is not going to be able to visualize what is included in the bullets for slit-lamp exam with a simple penlight. See this link for furthur info.......

http://www.webmd.com/eye-health/slit-lamp-examination

"The slit lamp exam uses an instrument that provides a magnified, three-dimensional (3-D) view of the different parts of the eye. During the exam, your doctor can look at the front parts of the eye, including the clear, outer covering (cornea), the lens, the colored part (iris), and the front section of the gel-like fluid (vitreous gel) that fills the large space in the middle of the eye.

Special lenses can be placed between the slit lamp and the cornea (or directly on the cornea) to view deeper structures of the eye, such as the optic nerve, retina, and the area where fluid drains out of the eye (drainage angle). A camera may be attached to the slit lamp to take photographs of different parts of the eye."