Remember that most of the special tests ODs order, require an Interpretation and Report (I&R) per CPT guidelines. Without an I&R associated to these tests, third parties are well within their rights to recoup any payment they have issued. An easy way to remember the required components of an I&R is to think about the four “Rs”:
- Reason for Test
- Results of the Test
- Reliability of the Test
- Recommendations for Care
Importantly, none of these items need to be lengthy. Clear and concise is the goal. See Example using the Posterior Pole test in RevolutionEHR for an OCT.
It can be odd to comment on the reliability of a test such as a fundus photo but, when in doubt, a quick good reliability, fair reliability, or poor reliability will suffice.