Limited Eye Exam Form
Download the form above.
Brief Vision Exam
BRIEF VISION EXAM
Name: Age: Date:
Va cc Vnear cc W x Add
sc sc x
M x Add
x
T
Impression: Refractive error
Normal exam
Other:
Plan: Rx = M
No Rx
Follow-up for additional ophthalmology evaluation
, M.D.
Eye History Form
EYE HISTORY
Name: Date:
Thank you for choosing our office for your eyecare. To better serve you, please answer the following questions:
- Do you wear glasses? c YES c NO
- Do you wear contact lenses? c YES c NO
- Do you have problems reading? c YES c NO
- Are you currently experiencing any eye symptoms? Please circle all that apply:
Eye pain Blurred Vision Eyelid Crusting Flashes of Light Halos
Discharge Light Sensitivity Double Vision Decreased Vision Floaters
- Have you ever had an eye injury? Please describe:
- Have you ever had eye surgery? Please list type, which eye and approximate dates:
R/L
R/L
- Are you currently using any eye medications? Please list name and how often used:
- Are you being treated for any medical conditions? Please circle all that apply:
Diabetes Heart Disease High Blood Pressure
Stroke Arthritis Other:
- What medications other than above are you taking? Please list:
- Are you allergic to any medications? Please list:
- Do you have any family history of eye problems? Please circle and list family relationship:
Glaucoma Cataract Retinal Disease Macular Degeneration
- Please circle any of the following that you would like more information about:
Radial Keratotomy Contact Lenses Cataract Surgery
Diabetic Eye Disease Glaucoma Other:
Special Testing Documentation Aids
OMIC is pleased to announce the development of some easy-to-use documentation aids for special testing services to provide appropriate documentation that will (1) withstand scrutiny in the event of a malpractice claim and (2) meet Medicare requirements as the federal government and its carriers demand increased documentation.
The aids, developed by Bill Sarraille, a health care attorney and frequent lecturer on fraud and abuse issues in ophthalmology of the Washington, D.C. office of Arent Fox Kintner Plotkin & Kahn, PLLC, and Heather Freeland, a Medicare reimbursement consultant, with the Duncanville, Texas health care consulting firm of Rose & Associates, are designed to assist eye care practitioners in complying with the CPT descriptors for nineteen “special testing services.” As Mr. Sarraille notes, “there has been a large number of overpayment demands in Medicare audits, and even criminal and Federal Civil False Claims Act cases, that have revolved around allegations that special testing services were not adequately documented.” Carriers and whistle blowers filing False Claims Act cases have charged that inadequate documentation constitutes “proof” that the services were not performed. Special testing documentation can also become critically important in a malpractice context. Plaintiffs’ attorneys will be “quick to argue that services either were not performed or not appropriately considered, if adequate documentation is not present,” Mr. Sarraille observed recently at an OMIC-sponsored seminar at the 1999 ASCRS/ASOA meeting in Seattle.
The special testing services are:
92060 Sensorimotor Examination
92081-92083 Visual Fields
92100 Serial Tonometry
92120 Tonography
92135 Scanning Computerized Ophthalmic Diagnostic Imaging
92140 Provocative Tests for Glaucoma
92225, 92226 Extended Ophthalmoloscopy
92230, 92235 Flourescein Angioscopy and Angiography
92240 Indocyanine-Green angiography
92250 Fundus Photography
92265 Needle Oculoelectromyography
92270 Electro-oculography
92275 Electroretinography
92284 Dark Adaptation Examination
92285 External Ocular Photography
92286, 92287 Special Anterior Segment Photography with specular endothelial microscopy and cell count
Documentation questions are common in the special testing area because of an important, but little noted change in the relevant CPT descriptors that occurred in 1996. Prior to that time, the CPT descriptors for most special testing services included the phrase “with medical diagnostic evaluation.” Beginning in 1996, however, the CPT descriptors were changed to say “with interpretation and report.” Unfortunately, neither the Health Care Financing Administration nor most of the Medicare carriers have supplied any meaningful interpretation of this vague “with interpretation and report” language. Check with your local carrier for any guidance it has published or otherwise issued.
In the absence of any carrier-specific requirements, Mr. Sarraille and Ms. Freeland recommend that practitioners billing for special testing services provide the following information in documenting special testing services:
- the results of the test;
- the findings and implications of the test results for the status of the illness; and
- the impact of this information on the patient’s treatment plan.
OMIC recommends making a document stamp which can be used to prompt documentation of these three elements for special testing services. The document stamp is designed to be used in connection with progress notes. The practitioner stamps the progress note for an encounter in which a special testing service was provided and then fills in the information as prompted by the stamp. Because at least one carrier appears to be requiring a “separate” interpretation and report for at least some special testing services, suggests developing separate sheets bearing the same prompts as contained on the stamps so that a report sheet that is separate from the corresponding progress note can be inserted into the patient’s medical record. A copy of a sample separate sheet form appears below:
|
Please be careful to note that a stamp and separate form interpretation and report may not reflect all of the documentation requirements for a special testing service. For instance, a number of carriers require that fundus photographs be maintained in addition to an “interpretation and report” for CPT 92250. Contact your local carrier for these additional documentation requirements.
Surgery Face Sheet
SURGERY FACE SHEET
CASE #: INS. CO:
AUTH #: PATIENT NAME:
SURGERY DATE: SURGERY TIME: AM PM
PLACE OF SERVICE/HOSPITAL:
TYPE OF SURGERY: OD OS PATIENT AGE:
ANESTHESIA: L.S.B. GENERAL DIABETIC YES NO
COUMADIN: YES NO
ANESTHSIA GROUP:
PRIMARY CARE PHYSICIAN:
PRE-OPT APPT. DATE: TIME:
POST-OP APPT. DATE: TIME:
KERATOTOMY QUALITY OF KERATOTOMY: GOOD AVG POOR
OD X @ OD
X @ AVG: X
X @
OS X @ OS
TECHNICIAN X @ AVG: X
X @
INFORMED CONSENT GIVEN: YES NO PRE-OP INSTRUCT GIVEN: YES NO
ACTIVITY SHEET GIVEN: YES NO POST-OP INSTRUCT GIVEN: YES NO
INFORMED CONSENT DISCUSSED (INCL SPECIAL RISKS):
A-SCAN (SCANS STAPLED ON BACK)
OD: QUALITY OF SCAN: GOOD AVG POOR
OS:
