In the proposal, a comprehensive examination will consist of eight or more elements and an intermediate examination, of seven or fewer of the specified elements. Only one of the two bulleted lines must be performed. Equally significant is the notation of positive and negative findings. For each element to be considered as having been performed, a notation must be made that it was done and what findings, if any, were present or were not present. In the absence of a negative notation for each element for each eye, it is presumed that element was not performed and, therefore, cannot be counted.
Preprinted charts are much easier and more efficient to use.
Technical personnel, residents, and physicians find using such charts less burdensome than writing, and it promotes complete charts. Now is the time to review your charts to ensure their use will produce chart documentation that complies with the new regulations. May 1997 Riva Lee Asbell is an ophthalmic reimbursement consultant and principal oF Riva Lee Asbell Associates, Philadelphia, Pennsylvania.