AS TECHNOLOGY maintains its torrid pace to reshape our clinical environment, special ophthalmic testing remains a mainstay of optometric practice. As a result, it is critical to understand CPT code requirements that define testing — any test — and its relationship to medical necessity.

The test you order and perform must be necessary (not convenient, desired or to embellish income) to diagnose, follow a diagnosis, treat or follow the treatment of a condition.


The CPT clearly defines, in “2017 CPT Professional Edition:” “Interpretation and report by the physician is an integral part of the special ophthalmological services where indicated and that the technical procedures (which may or may not be performed personally by the physician) are often part of the service, but should not be mistaken to constitute the service itself.”

Technically, a diagnostic test is not complete until the physician’s interpretation and report has been finished.


Common misperceptions about the interpretation and report:

  1. You need a specific form or a specific place in your EHR for an interpretation and report. False. Here is what is critical: There should be some distinct and separate area in your medical record, whether paper or electronic, in which you can create the interpretation and report for each test performed.
  2. You can create a “master” interpretation and report for all tests done. False. Each test performed requires its own interpretation and report — no exceptions.
  3. I do my interpretation and report in my “assessment and plan” for the office visit. Also false. The assessment and plan should contain the statement of medical necessity and the order for needed special ophthalmic tests.


The content of the interpretation and report is fairly standard. Remember the simplicity of the objective here. Because you have already established medical necessity for the procedure, the interpretation and report is to simply reflect in the medical record how you interpreted the test results and how it affected the care plan for the patient going forward. Here are the essential elements that should be contained within an interpretation and report.

  • Clinical findings. Pertinent findings regarding the test results.
  • Interpretation of the findings.
    * Comparative data. Comparison to previous test results (if applicable).
  • Clinical management. How the test results will affect management of the condition/disease going forward. For example:
    • Change/stop medication
    • Recommendation for surgery
    • Recommendation for further diagnostic testing
    • Referral to a specialist/sub-specialist for additional treatment

Simply performing the technical component of the test is not enough, nor is initialing the test to signify you looked at it. When a carrier finds that the interpretation and report has not been completed, the entire test is deemed invalid and financial recoupment/recovery will be for the test in total.


By properly completing the requirements of the CPT, including completion of an interpretation and report, for each diagnostic test performed, your patient benefits and you reduce your risk as well. OM