Wiki 92012- external and adnexal exams

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joyce

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I am new to opth coding. I need help understanding the exam elements. When Adnexal or external ocular exams are performed, what kinkd of language I am looking for. My provider documented:
Physical Examination
VA OD 20/20 OS 20/20 J1 CC. AR OD +2.25 sph - 0.75 cyl @ 105 OS +2.25 sph - 0.50 cyl @ 95 ADD +1.75 sph VA OD 20/20 OS 20/20 J1. IOP OD 15 OS 16. SLE clear corneas, AC deep, cortical lens changes OU. Fundi - healthy discs, CD ratio 0.2.

From what I see he has VA, cornea, IOP, anterior chamber, optic disc.

cpt states "general medical observation, external ocular and adnexal examination " are required elements for this level of care. Can anyone shed light on this!
 
I see VA, Cornea, refraction,IOP, corneas, anterior chamber,lens, fundus and c/d ratio.

This is a list of documenation I have from my education department on the required elements:



Base Ophthalmology Exam- visual acuity, tonometry, pupils, visual fields, EOM and dialation (even if it is to say it wasn?t done for XXX reason)

Main Ophthalmology Exam- External
Slit lamp (lids/lashes, conjunctiva/sclera, anterior chamber, iris, lens, vitreous)
Fundus, disc, C/D ratio, macula,vessels, periphery
Neuro/Psych, oriented X3 OR Mood/Affect
 
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