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Interpretatin and Report for eye procedures

  1. Default Interpretatin and Report for eye procedures
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    I have a question regarding I/R, I am noticing a pattern with our physicians that when they indicate a reason for the test they are writing something like this.

    Reason for Test - H40.1232 - low-tension glaucoma, bilateral moderate stage, Monitor for progression.

    Reason for Test - H40.013 - Open-Angle with borderline findings, low risk, Monitor for progression

    I am trying to teach them the correct way to document a chart, all the other pieces of the I/R are good, I am just not sure if something like this is okay.

    Any help and/or feedback would be greatly appreciated.


  2. Default
    I've seen wording like this used by several retinal specialists when ordering tests, such as OCTs, for patients with various retinal conditions.

    As long as the I&R itself meets the appropriate criteria, then I think you're in good shape.

    Tom Cheezum, O.D., CPC, COPC

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