Can anyone provide me with an "official" quote that defines "general medical observation" as it relates to the Medicine / Ophthalmology section of CPT? In the 2015 Professional Edition see CPT instructions on page 564 under the "Ophthalmology" header just before 92002.
It is my opinion that this is documentation of the provider's general, clinical observation(s) and that such observation(s) would typically be documented within the context of constitution / general appearance / general impression.
A non-coder peer believes that because it has specific mention in the instruction / definitions within this section, it should stand on its own and therefore be culled out separately. More specifically, that it should have it's own place of prominence in documentation and its own "field" in the EHR - separate from constitution and or exam notes.
If anyone can share insight and / or provide something that I can present as official vs. just my opinion, I would welcome hearing it - even if I'm wrong.
Please and thank you.
It is my opinion that this is documentation of the provider's general, clinical observation(s) and that such observation(s) would typically be documented within the context of constitution / general appearance / general impression.
A non-coder peer believes that because it has specific mention in the instruction / definitions within this section, it should stand on its own and therefore be culled out separately. More specifically, that it should have it's own place of prominence in documentation and its own "field" in the EHR - separate from constitution and or exam notes.
If anyone can share insight and / or provide something that I can present as official vs. just my opinion, I would welcome hearing it - even if I'm wrong.
Please and thank you.