Remember that most of the special tests ODs order requires an interpretation and report (I&R) per CPT guidelines. Without an I&R associated to these tests, 3rd parties are well within their rights to recoup any payment they’ve issued. An easy way to remember the required components of an I&R are 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. Here’s an 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” would suffice.
