Risk Management

Special Testing Documentation Aids

OMIC is pleased to announce the development of some easy-to-use documentation aids for special testing services to provide appropriate documentation that will (1) withstand scrutiny in the event of a malpractice claim and (2) meet Medicare requirements as the federal government and its carriers demand increased documentation.

The aids, developed by Bill Sarraille, a health care attorney and frequent lecturer on fraud and abuse issues in ophthalmology of the Washington, D.C. office of Arent Fox Kintner Plotkin & Kahn, PLLC, and Heather Freeland, a Medicare reimbursement consultant, with the Duncanville, Texas health care consulting firm of Rose & Associates, are designed to assist eye care practitioners in complying with the CPT descriptors for nineteen “special testing services.”  As Mr. Sarraille notes, “there has been a large number of overpayment demands in Medicare audits, and even criminal and Federal Civil False Claims Act cases, that have revolved around allegations that special testing services were not adequately documented.”  Carriers and whistle blowers filing False Claims Act cases have charged that inadequate documentation constitutes “proof” that the services were not performed.  Special testing documentation can also become critically important in a malpractice context.  Plaintiffs’ attorneys will be “quick to argue that services either were not performed or not appropriately considered, if adequate documentation is not present,” Mr. Sarraille observed recently at an OMIC-sponsored seminar at the 1999 ASCRS/ASOA meeting in Seattle.

The special testing services are:

92060 Sensorimotor Examination

92081-92083 Visual Fields

92100 Serial Tonometry

92120 Tonography

92135 Scanning Computerized Ophthalmic Diagnostic Imaging

92140 Provocative Tests for Glaucoma

92225, 92226 Extended Ophthalmoloscopy

92230, 92235 Flourescein Angioscopy and Angiography

92240 Indocyanine-Green angiography

92250 Fundus Photography

92265 Needle Oculoelectromyography

92270 Electro-oculography

92275 Electroretinography

92284 Dark Adaptation Examination

92285 External Ocular Photography

92286, 92287 Special Anterior Segment Photography with specular endothelial                                 microscopy and cell count


Documentation questions are common in the special testing area because of an important, but little noted change in the relevant CPT descriptors that occurred in 1996.  Prior to that time, the CPT descriptors for most special testing services included the phrase “with medical diagnostic evaluation.”  Beginning in 1996, however, the CPT descriptors were changed to say “with interpretation and report.”  Unfortunately, neither the Health Care Financing Administration nor most of the Medicare carriers have supplied any meaningful interpretation of this vague “with interpretation and report” language.  Check with your local carrier for any guidance it has published or otherwise issued.

In the absence of any carrier-specific requirements, Mr. Sarraille and Ms. Freeland recommend that practitioners billing for special testing services provide the following information in documenting special testing services:

  • the results of the test;
  • the findings and implications of the test results for the status of the illness; and
  • the impact of this information on the patient’s treatment plan.

OMIC recommends making a document stamp which can be used to prompt documentation of these three elements for special testing services.  The document stamp is designed to be used in connection with progress notes.  The practitioner stamps the progress note for an encounter in which a special testing service was provided and then fills in the information as prompted by the stamp.  Because at least one carrier appears to be requiring a “separate” interpretation and report for at least some special testing services, suggests developing separate sheets bearing the same prompts as contained on the stamps so that a report sheet that is separate from the corresponding progress note can be inserted into the patient’s medical record.  A copy of a sample separate sheet form appears below:



Patient Name:________________________   Date of Service:______________





Type of Service: _______________________________________________




Findings and Implications:_______________________________________




Impact on Plan:________________________________________________





Signature of Physician___________________________________________








Please be careful to note that a stamp and separate form interpretation and report may not reflect all of the documentation requirements for a special testing service.  For instance, a number of carriers require that fundus photographs be maintained in addition to an “interpretation and report” for CPT 92250.  Contact your local carrier for these additional documentation requirements.


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