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Hypertensive Retinopathy Billing Optometry

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sjholb:

What clinical signs do you need to bill for hypertensive retinopathy?

I was working with a Doc that was billing. OCT and extended opthalmoscopy and photos for patients that had initial signs. Like A/V nicking and low A/V and high ALR. The patients were already diagnosed with hypertension from their PCP.  There were no bleeds or hemes. Is this enough to bill? Will I get in trouble if audited?

Thank you

sjholb:
Hello... Am I posting this is the wrong section?

PMRNC:
This is a pretty specific clinical question on signs and documentation that no one here can  and shouldn't be answering. Your job as a biller is to bill what the physicians gives you and his job is to code or have a Certified Coder code from the medical record itself. As a biller you should be looking for obvious problems or mistakes that don't require the actual medical / clinical record. If your provider is giving you this to do coding and you are not an experienced and/or certified coder it's best to hand it back to him to look over.

Your question was this:
--- Quote ---"What clinical signs do you need to bill for hypertensive retinopathy"
--- End quote ---

Your provider should know what "clinical signs" should be documented. If it's not documented, it's not done, not done, no code.

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