Interpretation and Report

Every separately billable diagnostic test requires documentation of what is referred to as an interpretation and report.  Without this documentation, an auditor can deny reimbursement for the diagnostic test.  Unfortunately, there are not a multitude of specific guidelines related to interpretation and report findings. 

Without question, the interpretation and report can be contained within the body of the medical record but must be identifiable as a unique entry, separate from the normal examination findings.  This is best accomplished by having a “Special Testing” tab or section in your EHR.  This is already available to OfficeMate users.  For Crystal users, Dr. Cass has a customization that accurately documents special testing.

What exactly should be contained in the interpretation and report is the subject of much debate.  CPT does not state what it should contain, but many agree that you should consider documenting the following elements in any special testing:

•       The reason the test was conducted (can be just the diagnosis code)

•       A statement regarding the reliability of the findings 

•       A statement regarding patient cooperation during the testing                                     

•       A brief summary of the findings 

Some diagnostic tests have special or unique documentation requirements per individual payor payment guidelines.  The most common examples are extended ophthalmoscopy and pachymetry.


Joe DeLoach, O.D.

Optometric Business Solutions