In the retinal subspecialty, diagnostic testing represents a significant portion of services third-party payers reimburse. The most common testing we see in a retina practice includes scanning computerized ophthalmic digital imaging, otherwise called optical coherence tomography, fundus photography, fluorescein angiography, indocyanine-green angiography and extended ophthalmoscopy.

When we perform chart reviews, documentation associated with diagnostic tests is one of the top areas of exposure. Sometimes indications are not clear, and other times orders are missing; but the most common problem is with documentation of test interpretations.

Interpretations are often missing completely or lacking in content. In this article, I will discuss the documentation standards for diagnostic tests spelled out by Medicare.   

Test Orders
Every test that a physician delegates requires an order. The order, based on physician participation, provides the medical necessity for the test. Strict requirements for a physician order exist in the Code of Federal Regulations, which states:

All diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.1

Typically, an order for a test occurs after the physician evaluates the patient, which is most often the case for new patients. For established patients, test orders are often noted on the preceding exam as part of the plan for a return visit. In contrast, some scenarios do exist when the physician has not yet examined the patient, which may also support an order. They are:
• You receive a copy of chart notes from a referring ophthalmologist asking for a consultation, and, after reviewing the referring ophthalmologist’s chart notes, you order a diagnostic test to be administered upon the patient’s arrival.
• Your technician takes a history and performs a preliminary work-up on a new patient and finds something concerning. The technician brings the information to you, who is scheduled to see this patient soon, and you order an immediate diagnostic test based on the information.

A test personally performed by the physician does not require an order. For example, extended ophthalmoscopy cannot be delegated to ancillary personnel, so an order is not necessary, assuming the indications support the test.

Avoid the use of standing orders. Retina specialists understandably see patients for specific conditions. Establishing a protocol based solely on being a retina specialist does not support an order. Diagnostic test orders should be specific to a patient and generated on a case-by-case basis. Medicare carrier Wisconsin Physician Services stipulates that “standing” or “routine” orders for diagnostic tests are not reimbursable.2

The phrase “with interpretation and report” is part of Current Procedural Terminology’s (CPT) description for many ophthalmic diagnostic tests. Physicians often ask us, “What exactly does this phrase mean, and what kind of chart note is required?” Because diagnostic tests accompany almost every eye exam retinal specialists perform, this question takes on added urgency because insufficient chart documentation is reason enough to require repayment of any reimbursement as well as brings increased scrutiny from Medicare and other third-party payers.

The Medicare guidelines for interpretation of diagnostic tests are  discussed in the Medicare Claims Processing Manual (Chapter 13 §100) Interpretation of Diagnostic Tests. The Centers for Medicare and Medicaid Services distinguishes between a review of a test and an “interpretation and report” accordingly:

Carriers generally distinguish between an “interpretation and report” of an X-ray or an EKG procedure and a “review” of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment.3

The review of a test is not separately payable because it is part of an E/M service (i.e., an office visit).

For example, a notation in the medical records saying “fx-tibia” or “EKG-normal” would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An “interpretation and report” should address the findings, relevant clinical issues, and comparative data (when available).3

Brief notations like “normal, abnormal”, or “stable” are construed as a review of the test rather than as an interpretation and report. Define “normal” for each test and use that definition for the occasional normal test results.

Questions a Report Should Answer
Furthermore, noting only the diagnosis as an interpretation is also deficient. Do not overlook a comparative statement regarding the results. Many of the tests retinal specialists order track changes in chronic conditions like age-related macular degeneration and diabetic retinopathy. Consider answering the following questions for a test interpretation:

• What are the results of the test?
• What do the results mean and how do they compare to previous test(s)?
• What are you going to do about the results?

For example, for an OCT, the most common test billed by ophthalmologists within the Medicare program, the “interpretation and report” might read as follows:
• Subretinal fluid with pigment epithelial detachment OD.
• Increased subretinal fluid showing new active wet AMD since last exam 6 wks ago.
• Recommend anti-VEGF injection OD.

Diagnostic tests are a significant part of most practices, so do not underestimate the importance of an obvious order and a thorough “interpretation and report.”  RS

Mr. Mack is a senior consultant with Corcoran Consulting Group. He can be reached at 1-800-399-6565 or at

1. Centers for Medicare and Medicaid Services website. 42 CFR §410.32: Diagnostic X-ray Tests, Diagnostic Laboratory tests, and Other Diagnostic Tests: Conditions. Available at:  Accessed May 26, 2016.
2. Wisconsin Physician Services website. Recognizing The Meaning Of “Standing Orders”. Available at: Accessed May 26, 2016.  
3. Centers for Medicare and Medicaid Services website. CMS Medicare Claims Processing Manual (MCPM);  Chapter 13 §100: Interpretation of Diagnostic Tests. Available at: Accessed May 26, 2016.