Wiki Interpretatin and Report for eye procedures

[dalanicks@aol.com]

hi

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.


laura

 

[Cheezum51]

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