Case History (Hx)

• Patient’s chief complaint or reason for exam
• Ocular and visual health history (your patient and family, past and present)
• General health status (e.g., significant illnesses and medical conditions)
• Current medication and medication allergies
• Occupational and vocational visual demands

Ophthalmoscopy

At minimum, a nerve head assessment, including a numerical cup-to-disc ratio or hand-drawing of cupping is required to satisfy this requirement. If the C/D ratio is the same for each eye, indicate OU. If different for each eye, document OD and OS accordingly. Ophthalmoscopy may be done with or without diagnostic pharmaceutical agents (DPAs)*.

In addition, we advise you record the following:

• Vascular assessment, including A/V size ratio or grading of hypertensive or arteriosclerotic retinopathy changes;
• Descriptive retinal findings, macula assessment and grading of foveal reflex brightness;
• Observations of media.

*Note: We consider Fundus photos and Optomap retinal exams separate procedures. They’re not acceptable in lieu of performing direct or indirect ophthalmoscopy.

Neurological Integrity
(pupil reflexes)

Record descriptions of normal pupillary reflexes, such as “equal, round, reactive to light and accommodation (PERRLA),” WNL, pupils R&R (round and reactive), -APD, Ø APD, direct and consensual, and/or -Marcus-Gunn. Also, clearly record deviations from normal responses with diagnostic impressions. Measurement and documentation of pupil size in one level of illumination alone is not acceptable.

Versions

Record assessments of extraocular muscle motility, such as “full and smooth,” FROM (full range of motion), SAFE, 1-4+, unrestricted, etc., describing any deviations from normal. Must be documented separately from binocularity testing results.

External/Adnexa Exam

Record lids, lacrimal apparatus, sclera and conjunctiva as “clear,” describing any deviations from normal in the ocular adnexa.

Biomicroscopy (SLE)

When recording slit lamp exam, include a description of anterior segment, corneal clarity, media clarity or anterior chamber angle quantification.

Anterior segment photos are separate procedures. They’re not acceptable in lieu of biomicroscopy without separate documentation of anterior segment findings.

Screening Visual Fields

Gross visual fields or confrontation testing is acceptable for the comprehensive level of service. Record any depressions found in the gross visual fields or confrontation testing. Record a normal finding as “negative, WNL, FTFC (full to finger count), full in all quadrants, etc.” or taken from automated visual field printouts. At minimum, a tangent screen is an acceptable device used to get gross visual fields.

For visual field screening, at minimum, evaluate and record at least two meridians of visual field. Vision screeners that only test or measure single meridian fields won’t be accepted.

Tonometry

Record a numerical pressure measurement for each eye, type of instrument, date and time performed. Tactile estimations of intraocular pressure are only acceptable if there’s a documented reason for not having done a quantitative measurement.

If tonometry is omitted for any reason on an adult, bill a lesser level of service. For pediatric patients, tonometry is a guideline, not a requirement. Attempt tonometry, either applanation or noncontact, at the earliest age the child is cooperative.

Visual Acuity (VA)

Record monocularly as:

• Entering visual acuity (at 20 ft) with habitual Rx or unaided. Document monocular distance acuities for each eye for monovision contact lens patients.
• Best corrected visual acuity at distance through the subjective refraction.
• your patient can’t respond properly to testing (e.g., non-verbal or illiterate) please indicate in your documentation.

Subjective Refraction

Determination of refractive state with best corrected visual acuities (recorded monocularly). Testing may be delegated to qualified staff under the supervision of a licensed VSP Network Doctor (as permitted by state regulation) and may be done with or without DPA's (diagnostic pharmaceutical agents)

Subjective refraction must be performed without spectacle or contact lenses. The only exceptions to this rule are:

• Spectacle overrefractions are acceptable if your patient can’t respond properly to subjective testing (e.g., non-verbal, illiterate patients) and are recorded quantitatively.
• Contact lens overrefractions are acceptable only in cases of corneal irregularity where the manifest refraction is inconclusive (keratoconus, corneal transplants, dystrophies, etc.).

For the above exceptions, indicate why you couldn’t perform the subjective Rx.

Accommodative Function

Accommodative Function is a guideline based on the doctor's professional judgment and not an exam requirement. Any near point accommodation testing (pediatric and adult exams) is performed when clinically indicated.

Diagnosis

Document the diagnosis on the exam chart. The diagnosis must be supported by the documented clinical findings.

Any charge to your patient for special testing procedures must be supported by a recorded diagnosis. Diagnoses, either written or coded, must have an ICD-9-CM billable code.

Always code to the highest degree of specificity when indicating diagnosis.

A diagnosis taken from an eClaim printout, CMS-1500 Form, WellVision Savings Statement, or a superbill isn’t acceptable unless it’s signed, initialed, or has some unique identifer by the doctor. Subjective Rx findings, a written Rx copy, or optical materials order are not acceptable in lieu of the written diagnosis.

Treatment Plan

The treatment plan should be consistent with the diagnosis and/or reflect the clinical findings. The treatment plan/therapies can include specific treatments or documentation that no therapy was needed.

Documentation of a treatment plan by the doctor is required in the patient’s chart notes. Record the instructions provided to your patient.