By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
July 5, 2017
Many of the procedure codes we use in medical coding and billing require a report. What needs to be contained in that report? Here are the four areas you need to address in your report: tests; comparative data; clinical management; and signature/date. Let’s look at these one at a time.
In reporting on the tests done, you need to describe the medical necessity for the tests done, the actual tests done and the reliability of the results of the tests. For medical tests to be paid by medical insurance companies, there must be medical necessity for administering the tests. In the absence of medical necessity, the test is to be paid out-of-pocket by the patient. (If a procedure is being paid out-of-pocket it is always a good idea to have an Advanced Beneficiary Notice signed by the patient.)
Describing the actual tests done can be achieved by just naming the test. (In your medical documentation, be sure to name where the test results can be found if they are not attached to the patient file. For example, if your retinal camera is not linked to your practice management software, you need to explain that the test results are on the retinal camera hard drive under the patient’s name.)
Reporting on the reliability of a test only has two answers: reliable or unreliable. Remember the medical documentation rule that if you state that anything is a problem you must further describe it in words or pictures. If the test results are unreliable, you must state why. Was the patient uncooperative, was the instrument out of order, did the electricity go out in the middle of the exam? Explain why the test results are unreliable.
COMPARATIVE DATA (CHANGES SINCE THE LAST TEST)
Comparative data is asking you to describe the changes since the last test. In reporting on Comparative Data, there are four possible answers: First Test Ever Done; Improving; Stable; or Worsening. The same rule applies here as was described under TESTS. If the answer is Worsening, it’s not enough just to state “worsening” – you must explain in words or pictures why the results are worsening.
CLINICAL MANAGEMENT (IMPRESSION, ASSESSMENT & PLAN)
In reporting on Clinical Management, you want to address your impression of the case, your assessment of the case, and your medical plan for moving forward with the case. The easy way to think of this is what changes are you making to the medical plan for this patient as a result of doing these additional tests? There are really two answers here: no changes and changes. If the tests confirm your working diagnosis and support staying with your initial plan, then no change is necessary, so state that. But if the tests give you a new or different understanding of the case, then a change in the medical plan may be necessary and you need to state the change and why.
As with any medical documentation, you must sign and date your record. With electronic medical records, the software signs and dates the record for you (as long as you have the software set up appropriately). If you are still in paper records, then don’t forget to sign and date the report even if you are the only doctor in the practice and the report is just being placed in the record because the procedure required you write a report.
The next report you write, keep this outline in mind. If you follow this outline you will hit all of the areas that auditors are looking for in your reports and, at the same time, communicate clearly your medical thinking about the case.