Medical-Record Documentation
Requirements
The medical-record review ensures the doctor meets our documentation requirements.
Per HIPAA Rules, VSP Network Doctors must keep all medical records and have them accessible for six years (ten years for Medicare managed care program providers) or as required by federal/state laws, from the date of its creation or the date when it last was in effect, whichever is greater.
Medical records should be complete and legible; and should include the legible identity of the provider and the date of service.
Our definition of a medical-record is: “The documentation recorded by the doctor regarding the patient’s medical history, as well as every encounter between the doctor and the patient, and all information shared with the doctor related to other encounters with other doctors.”
For example:
- Patient history questionnaires or “welcome to the office” forms;
- Exam chart notes and follow-up related to the same date of service;
- Visual field, topography, auto-refractor, auto-keratometery or tonometry either electronic or hard copy documentation;
- Referral summaries and letters;
- Optical records and lab order forms, including spectacle order forms/sheets and contact lens order forms/sheets;
- Superbills, eClaim billing printouts, or CMS-1500 Claim Forms; and
- For services provided in Long Term Care Facilities, include PCP orders.
Note: Fundus photos and Optomap retinal exams are not acceptable in lieu of performing a direct or indirect ophthalmoscopy. These are considered separate procedures.
Anterior Segment photos are also considered a separate procedure from biomicroscopy; and are not acceptable in lieu of biomicroscopy without separate documentation of anterior segment findings.
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Medical Record Requirements |
Description |
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Comprehensive or Intermediate Exams meet VSP guidelines |
Ensure all procedures are documented following our recording guidelines for the level of service provided (explained in the Eye Exams section). Undocumented procedures are considered not performed unless the test was attempted and there is documentation as to why results were not obtained. Examples include: the patient is non-verbal, non-responsive, illiterate, uncooperative, refused testing, etc.). |
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Exam and claim record is the exact date the patient was seen |
The exam date and date of service on the claim must be the same date the patient was seen. Inaccurate dates on a claim can negatively affect your patient’s vision care coverage in the future. |
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Past medical history |
Record the patients past medical history including childhood diseases, past surgeries, illnesses, injuries, family medical history and the date of last eye exam or physical, old glasses or contact lens Rx. Note any information that’s unobtainable. |
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Current significant illnesses and medical conditions |
Document and date any significant patient illnesses or medical conditions (or the absence of chronic problems) in the medical record or currently updated history form. |
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Current medications |
Clearly document and date current medications. Medications should relate to the patients’ specific condition(s). Also record “no medications” taken by the patient |
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Current medication allergies and reactions |
Clearly document and date current medication allergies or reactions. List patient allergies to medications on the patient’s chart. Also record “no known medication allergies/reactions”. |
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Subjective/objective information |
Subjective information must show the patients presenting reason or complaint for the exam. Objective information documents physical findings related to the presenting complaint, including both normal and abnormal findings. If the patient presents with “no complaint – routine exam” the level of exam billed must meet all service requirements for that exam level. |
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Diagnoses and exam findings are consistent |
A diagnosis must be documented for each visit and support the documented clinical findings. The diagnosis (written or coded) must be recognized as an ICD-9-CM code. *Note: V72.0 is not acceptable as the sole diagnosis with a date of service on and before 9/30/15 if there is another more appropriate refractive or medical diagnosis to use. |
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Diagnoses and treatment plan or therapies are consistent |
Documentation should include all treatments, such as glasses, contact lenses, medication therapy or visual training. An order for optical materials, a written Rx copy or a note stating, ‘no treatment’, can meet this requirement. Treatment plans/therapies must be appropriate and consistent with the diagnosis. If a diagnosis isn’t noted, the treatment plan should reflect the clinical findings. |
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Follow-up care/visits |
Exam notes must indicate a specific time frame when your patient should return (one month, one year, etc.). Computerized recall documentation alone isn’t sufficient. Electronic records must have recall dates present within the medical record and a Doctor identifier must also be present. |
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Signed entries |
Indicate the doctor’s initials, full signature or electronic identification on all chart notes, from the claim date forward. |
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No potential risk for Patient |
Doctor interventions are appropriate for the clinical findings, patient history/complaints, and the diagnoses. There should be no indication that a patient was placed at potential risk due to diagnostic or therapeutic procedures given or not given. |
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Complete diagnostic contact lens procedures |
Make sure all procedures for first-time contact lens wearers and refit patients are recorded following our recording guidelines. |
Note:
For California patients, include the following documentation. Refer to the VSP Members Language Assistance Program for more information.
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Patient’s preferred written and spoken language. |
Include the patient’s preferred written and spoken language on the patient history form and/or medical record. |
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Refusal of interpreter |
If patient prefers a language that is not provided in the office and refuses the use of a trained, professional interpreter, document the refusal in the patient medical record or on the refusal form used by your office. Note: A trained, professional interpreter does not include friends or family members, unless the person is professionally trained, including knowledge of medical terminology. |
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Use of interpreter |
Document the use of an interpreter in the patient medical record or the use of interpreter form used by your office when a person is providing interpreter services for the patient requiring interpreter services. Document who provided the interpretation (trained professional interpreter, office staff, family member, minor, friend, etc.) |
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Appointment timing |
If an appointment is delayed or extended, note in the relevant record that a longer waiting time would not have a detrimental effect on the health of the patient. |