Diagnostic Procedures in Ophthalmology 2nd Edition

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The purpose of sections I and II of this chapter is to provide an overview of the ocular history and basic complete eye examination as performed by an ophthalmologist. In section III, more specialized examination techniques will be presented. The chief complaint is characterized according to its duration, frequency, intermittency, and rapidity of onset. The location, severity, and circumstances surrounding its onset are important, as is identifying any other ocular and nonocular symptoms that may require specific enquiry.


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Current eye medications and current and past ocular disorders are determined. The past medical history must include enquiry about vascular disorder—such as diabetes and hypertension—and systemic medications, particularly corticosteroids because of their adverse ocular effects. Finally, any drug allergies should be recorded. The family history is pertinent for ocular disorders, such as strabismus, amblyopia, glaucoma, or cataracts, and retinal problems, such as retinal detachment or macular degeneration.

Medical diseases such as diabetes may be relevant as well. A basic understanding of ocular symptomatology is necessary for performing a proper ophthalmologic examination. Ocular symptoms can be divided into three basic categories: abnormalities of vision, abnormalities of ocular appearance, and abnormalities of ocular sensation—pain and discomfort. Symptoms and complaints should always be fully characterized. Was the onset gradual, rapid, or asymptomatic? For example, was blurred vision in one eye not discovered until the opposite eye was inadvertently covered?

Was the duration brief, or has the symptom continued until the present visit? If the symptom was intermittent, what was the frequency? Is the location focal or diffuse, and is involvement unilateral or bilateral? Finally, does the patient characterize the degree as mild, moderate, or severe? One should also determine what therapeutic measures have been tried and to what extent they have helped.

Has the patient identified circumstances that trigger or worsen the symptom? Have similar instances occurred before, and are there any other associated symptoms? The following is a brief overview of ocular complaints.


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Chart Documentation, Coding, Scribing, Triage. Comprehensive Clinical Ophthalmology. Contact Lenses, Spectacles, Optical Dispensing. Diagnostic Testing and Imaging. General Ophthalmic Knowledge. Instruments and Specialized Tests. Low Vision and Treatment. Ocular and Systemic Diseases. Refractive and Cataract Surgery. Surgical: General. Visual Assessment and Therapy.

Visual Fields. Contact Lens Fitters and Opticians. Contact Lens, Spectacles, Optical Dispensing. Ophthalmic Nurses. Ophthalmic Photographers. Practice Managers.

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Exam Prep. There are basically three modifiers that are used in conjunction with billing for diagnostic tests: modifiers 26, TC and 52 Table 1.

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Neuro-Ophthalmology: Diagnosis and Management (2nd ed.) : Optometry and Vision Science

However, there are a few ophthalmic diagnostic tests that are considered only a physician service and are not divided into a professional and technical component. It is assumed that these tests are performed solely by the physician. Among these are extended ophthalmoscopy and gonioscopy. A complete list is provided in Table 2. Modifiers 26 and TC. Placing modifier 26 after the CPT procedure code indicates that only the professional component is being billed. Placing modifier TC after the CPT procedure code indicates that only the technical component is being billed.

Thus, if only the interpretation and report is performed, then append modifier 26 to the claim entry; if only the test itself is performed and there is no interpretation and report, append modifier TC. Ophthalmic ultrasound and biometry by partial coherence interferometry.

Diagnostic Procedures in Ophthalmology

Ophthalmic ultrasound with intraocular lens calculation CPT code is a special case example wherein the professional component is considered a unilateral code and the technical component is a bilateral code. This is also true for ophthalmic biometry by partial coherence interferometry CPT code See modifier 52 for explanation of unilateral and bilateral code differentiation for payment. For those of you who may not have mastered this yet, here are some clinical scenarios with proper coding.

This applies to both codes.

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Example 1: A patient is examined and found to have a mature cataract in the right eye and surgery is scheduled. There is no significant problem in the left eye. The correct coding would be RT.

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Many physicians like to have measurements on both eyes, but in the absence of medical necessity for performing the test, it would not be correct to bill the second side at this time. The code billed is the global one and includes both the professional and technical components. Example 2: A patient is found to have bilateral cataracts that need to be operated on, and the decision is made to do surgery on both eyes, with the right eye being scheduled first. The correct coding would be and TC.

Example 3: The patient in example 1 returns 6 months later and decides that she wants surgery for the left eye. Measurements had been taken initially, but only the right side was billed. It would now be appropriate to bill for the left side.