[OneSpot Podcast Resource] Audit-Ready Documentation: Interpretation and Report, Resource 1

202512: The OCT shows a normal retina. Now what?

Optical Coherence Tomography (OCT) has become an essential diagnostic tool in optometry, particularly for evaluating retinal conditions. However, when OCT results return normal findings, coding for these tests requires careful consideration to ensure both compliance and financial clarity for patients.

When patients present with symptoms such as blurred vision and no obvious pathology is identified, an OCT is often performed suspecting conditions like cystoid macular edema. The results may indicate that no pathology is present. Now what? In such instances, it is imperative to code appropriately to accurately reflect both the test performed and the outcomes.

It's important to note that there is no specific "rule out" diagnosis code in the ICD-10 coding system. Using a diagnosis code for a condition that you are investigating, such as cystoid macular edema, when OCT results do not confirm its presence is not appropriate. Accurate coding should reflect the findings of the examination. If the OCT reveals no abnormalities, it is essential to avoid coding for the suspected condition and instead use symptom-based codes or other appropriate diagnostic options. This practice ensures compliance with coding guidelines and maintains the integrity of patient records.

Coding for Normal OCT Findings

1. Identifying the Correct ICD-10 Code: In cases of normal OCT findings, coding should still relate to the reason for testing based on the patient's presenting symptoms. For instance, you might consider using codes like:
• H53.1: Blurred vision
• H54.7: Unspecified visual loss

However, it's important to note that these symptom codes may not qualify for reimbursement based on Local Coverage Determinations (LCDs) concerning OCT testing.

1. CPT Coding for OCT:
• Use CPT code 92134 for traditional retinal OCT or CPT code 92137 for OCT angiography. Accurately documenting the procedure, along with the findings that illustrate normal anatomy, is crucial for coding compliance.
2. Financial Implications for Patients:
• Patient Responsibility: Since many insurance plans do not cover OCT when the findings are normal, clearly communicate this to patients. It is essential to inform them that they may be responsible for the costs associated with the OCT testing before you perform the testing.
• Common Practice Among Doctors: In many instances, doctors opt not to bill patients for these tests with normal results to avoid surprising them with unexpected charges. This approach helps maintain transparency and trust with patients regarding their care.
3. Interpreting and Reporting Findings: The Interpretation and Report (I&R) should succinctly state that no abnormalities were found. Example components include:
• Findings Section: "OCT imaging reveals a normal retinal structure with no evidence of cystoid macular edema or any other abnormalities."
• Conclusion Section: "The OCT results are unremarkable, consistent with normal anatomical structure. Further monitoring may be considered depending on the patient’s symptoms."

Effectively coding for OCT examinations that yield normal findings requires a careful balance between medical necessity and financial transparency. By educating patients about potential charges and accurately documenting findings, optometrists can provide quality care while navigating the complexities of insurance reimbursement. This approach fosters clear communication and helps prevent any surprise billing issues for patients.

As you implement these strategies, adherence to updated coding practices promotes informed decision-making for both practitioners and patients.

CPT 99211: Understanding the Definition, Its Limits, and Common Billing Errors

CPT code 99211 remains an active evaluation and management (E/M) code and continues to be a source of confusion in optometric practices, particularly when applied to technician-performed diagnostic testing such as visual fields (VF) or optical coherence tomography (OCT).

The official CPT definition of 99211 is:

“Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.”

This definition is often misunderstood. While 99211 does not require the physician’s presence, it still represents an evaluation and management service. In other words, it is a non-physician visit, but it is not simply a “technician visit” performed in isolation.

A non-physician visit means the service is provided incident to the physician’s plan of care and under appropriate supervision. It must involve a medically necessary E/M service that contributes to patient management. Simply having a technician interact with a patient does not automatically qualify the encounter as a billable office visit.

Historically, many practices incorrectly used 99211 on days when a technician performed special testing and the doctor did not see the patient. The assumption was that because a technician performed work, a low-level office visit could be billed. This was incorrect then and remains incorrect today.

For 99211 to be billed appropriately, there must be documentation of an actual E/M service beyond diagnostic testing. Examples may include:

• Visual acuity measurement performed as part of an assessment
• Intraocular pressure measurement contributing to ongoing management
• Limited history or evaluation related to an established treatment plan

The key requirement is that the service must represent evaluation or management, not merely the performance of a test.

This distinction is especially important when special ophthalmic testing is involved. CPT codes for VF, OCT, and similar diagnostic tests already include the physician’s professional work:

• Interpretation of the test
• Medical decision-making related to the findings
• A documented report

Because this physician work is bundled into the diagnostic test code, billing an additional E/M service solely because a technician performed the test, or because the doctor later reviewed the results, constitutes unbundling.

An analogy from outside of eye care helps clarify this concept. If a patient undergoes an MRI ordered by their physician, the reimbursement for the MRI includes the radiologist’s interpretation and report. If the ordering physician later calls the patient to explain the results, the patient would not expect to be charged for an office visit simply to receive that information. The professional interpretation was already paid for as part of the diagnostic test. The same principle applies to ophthalmic testing.

Under current billing rules, if a patient presents only for diagnostic testing and the doctor later reviews, interprets, and documents the results, whether the same day or at a later time, no additional E/M service should be billed if no office visit occurred.

This includes situations where:

• The doctor reviews results asynchronously
• Results are communicated by phone or patient portal
• No separate, medically necessary E/M service takes place

Communicating test results alone does not create a billable office visit.

CPT 99211 may only be billed when a true office visit occurs that is separate from the diagnostic test itself. Examples include:

• An in-office evaluation related to new symptoms
• A management decision beyond test interpretation
• Services performed incident to the physician’s plan of care that meet E/M criteria

In these cases, documentation must clearly support that an evaluation or management service occurred and that it was medically necessary.

The key takeaway is that 99211 is a non-physician E/M code, not a catch-all technician visit code. Diagnostic testing codes already include physician interpretation and reporting, and reviewing or communicating results at a later time does not justify billing an additional office visit. Proper understanding of this distinction helps optometric practices remain compliant, reduce audit risk, and ensure accurate billing.

p202402 – A Complete Interpretation & Report is NOT Optional

Many of us are not great at documenting a proper interpretation and report (I&R). I&R’s are required for OCTs, fundus photos, visual fields, topographies, ERGs, VEPs, and many more. Special tests that don’t need an I&R are those like pachymetry where the result is a numeric number, and there is not much else that needs to be said. An easy way to find out if a test requires an I&R is to look in the current year’s CPT book. If the description of the code includes the words: “…with interpretation and report,” it requires an I&R. If you look up 92250, it states, “Fundus photography with interpretation and report.” If you look up 92020, it states, just “gonioscopy.” That means you just need to document the findings, but no formal report needs to follow. This has been a rule for decades, yet it is surprising how often I don’t find an I&R documented when doing audits. The reason this is such a big concern is if the I&R is not complete, the test is not billable. The report is just as much of a requirement as the performance of the actual test. In an audit, any payment for a test that is incomplete would be recouped. A visual field with a check mark on it or the letters “WNL” won’t cut it.

The documentation does not need to be a novel, but it must include five things: the Order and the “4R’s.” All testing requires a written order in either the chart on that day or in a previous chart. That means a legitimate order could be found in a prior day’s visit. If a patient presented for her annual exam, and you find suspicion of glaucoma, you could write: “Glaucoma suspect - RTC within 1 month for 24-2, RNFL OCT, pachy, and gonio.” This statement clearly states the tests needed and the reason for them. In other cases, the need for the test is determined and the order is written during the same visit when the test is done.

Once the order has been established, and the test has been performed a complete I&R needs to be documented either in the chart of that day, in a separate I&R document, or directly on the test’s printout. There is no rule that says where the I&R needs to be; you just need one! If the I&R is not directly in the chart, it is best to have a statement like, “I&R on printout.” This would clearly direct an auditor where to find it.

The “4R’s” of an I&R are:

Reason for the test • Reliability of the test • Results of the test • Recommendations based on the results

An I&R does not need to be long or complex. A simple statement such as one of these below is perfectly acceptable. Nothing fancy, just complete. 

These examples certainly take more time to write than just “WNL.” But they take less than a minute. Not only is it required by the payers, it provides better patient care. Imagine getting an MRI that just said, “WNL.” Or one with “defect” and an arrow pointing to something. Your report needs to contain enough info to explain the results and what you are going to do with that information.

Some EHR’s have provided doctors with a false sense of a what an I&R can be. Numerous times I have come across very generic I&R’s that don’t provide any useful information. For example, generic statements like, “OCT performed to monitor and provide progression analysis,” is not helpful. That’s just a definition of what any test is for! Nor is it useful to only state, “RNFL average thickness 78u.” You need to say what the data means…this is the interpretation part. “78u” for the RNFL could mean glaucomatous thinning, or it could mean the patient as peripapillary atrophy and that is just the way they are. You need to “interpret the data.”

Once you get used to the pattern of documentation, an I&R can typically be completed on-the-fly while seeing the patient. Ultimately, another doctor should be able to read just the I&R and understand what test was done, why, what it showed, and what is being done now. They shouldn’t even need to look at the actual test to understand what is happening.