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Ophthalmology and Optometry Coding Alert

What Documentation Must the Record Include?

Published on Mon May 17, 2021

When submitting a claim for an ophthalmic test, the record must include any photos, scans, or other hard copies as proof that the test or tests were performed. In addition, the documentation should contain: An order for the test with medical rationale The date of the test The reliability of the test (e.g., patient cooperation) The test findings A diagnosis, [...]
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