To assure compliance with Medicare requirements for billing and reimbursement of comprehensive exams for new and established patients (CPT codes 92004 and 92014), NEEI adheres to the CPT definition of a comprehensive exam. CPT 2008 defines a comprehensive eye exam as follows:

Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

From this definition NEEI interprets the essential elements of a comprehensive eye exam (for which the attending doctor is personally responsible for performing except 1.b. and 1.c. below) to include the following minimum data set:

1. Comprehensive eye and health history and history of present illness

   a. History of present illness, physical exam findings and medical decision making must be documented by attending doctor.

   b. Optometry students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.

   c. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

2. General medical observation
3. External ophthalmic examination
4. Ophthalmoscopic examination
5. Gross assessment of visual fields
6. Sensorimotor assessment
7. Diagnosis
8. Treatment

Optional features of a Medicare compliant examination include:

1. Biomicroscopy
2. Dilated ophthalmoscopic examination
3. Tonometry

NEEI’s interpretation of Medicare rules for a comprehensive eye exam does allow for the involvement of optometry students in portions of the exam. However, to be Medicare compliant, the attending doctor is required to personally perform (or repeat) the essential parts of the examination listed above, except for the review of systems and/or past family/social history which may be documented by students.

Furthermore, the diagnosis and treatment plan must be supported by procedures actually performed by the attending doctor.(For example, a diagnosis such as glaucoma would require tonometry – in most cases – and thus tonometry would have to be performed (or repeated by the attending doctor.)

It must be clear from a record audit that the diagnosis and treatment were arrived at solely based on the attending doctor’s examination. The attending doctor must be able to advocate the position that the student’s findings were not considered in making decisions.

Additionally, NEEI’s compliance protocol states that the history of present illness, diagnosis, and treatment are essential exam components and thus the accompanying documentation of these essential elements are to be completed by the attending doctor, either by handwritten notes, through dictation and typed record, or via computer generated and typed method.

The NEEI Medicare compliance protocol does not require that the attending doctor repeat non-essential elements of the exam or elements that are not covered by Medicare, such as refraction.

The NEEI Comprehensive Eye Exam Form (.pdf)

The NEEI comprehensive eye exam form has a column for the attending doctor to document essential elements. The form also has space for exam procedures such as biomicroscopy and other elements of an exam that would be repeated by the attending doctor as a matter of course.

The section for the student’s assessment and plan are placed on a separate sheet at the end of the exam form, after the attending doctor’s assessment and plan. This is to assure compliance with Medicare guidelines and the independence of the attending doctor’s conclusions from those of the student.

Mark O’donoghuem
Roger Wilson
Charles F. Mullen

The Medicare Regulations are written for the teaching hospital and its medical residency training model and translating the regulations language to the optometric clinical training model is difficult. Medicare generally does not recognize student-provided services as billable. (1)

Application of Medicare Regulations

Examination procedures performed by optometry students cannot be billed to Medicare and some third- party plans, with the exception of the student collected Review of Systems data (e.g. any heart problems, breathing problems, allergies etc?) This is the only element of the examination that does not have to be repeated by the billing physician.

Students may “practice” by performing the entire examination but their findings cannot be used or referred to in order to bill Medicare with the exception of student collected Review of Systems data.

The billing physician (preceptor) must repeat the examination with the exception of Review of Systems, ignoring the student’s findings, and document all findings and the management plan in his/her hand writing or by computer entry using the preceptor’s entry code. (2)

Comments Related to Applying Medicare Regulations as Written

“Incident to” or physician extender rationale does not apply, since students are usually not employed or compensated and the regulations are clearly addressing student participation. However, if a student on an externship is employed by the billing physician, the physician extender or the services “incident to” rules may apply.

There is no recognition in the regulations for optometry’s competency-based progression of students in their clinical training program. All optometry students must be supervised in the same manner whether they are in their 2nd, 3rd or 4th professional year of clinical training. The regulations prevent billing for the gradual increase in student responsibility for patient evaluation and management. Medical students who receive some of their patient management training in clinical clerkships during the 3rd and 4th year of medical school are also not eligible for Medicare payment. However, post graduate residencies in medical specialties are recognized as contributing to the diagnosis and treatment of patients and Medicare permits teaching physicians to bill for services provided by residents. In contrast, optometry students must be prepared to practice after completion of their fourth professional year and are currently not eligible for participation in the Medicare program.

The regulations do not apply to procedures performed by the student in the course of the “practice examination” that are not billable to Medicare, e.g. refraction.

Implications of Applying Medicare Regulations as Written

If examination of a Medicare patient is “complaint driven,” it is billable to Medicare but a one physician to one student supervision ratio would be required. The other option is that the billing physician repeats the entire examination.

Repeating the examination places an extraordinary burden of time and personal inconvenience on the Medicare Beneficiary which would likely force the Beneficiary away from a source of accessible eye care.

Patient services revenues would be reduced because of the extra time required to repeat the examination by the billing physician. One to one supervision would not be financially feasible since most optometry schools operate their own clinical training program for at least one class of students. The financial implications of increases in the clinical work force and reduction of revenues would be significant for many schools and colleges of optometry.

The financial implications of applying the Medicare regulations also would likely result in the Medicare population being restricted in optometric teaching clinics; resulting in reduced access to care for Medicare Beneficiaries and a clear detriment to the students’ clinical education.

Institutional externship sites such as Federal facilities and established medical institutions have their own student supervision directives. In general schools and colleges of optometry generally do not always know if private practice externship sites strictly apply Medicare regulations, although it is recommended that externships follow Medicare regulations and the externship sites supervise optometry students accordingly.

Conclusion

There does not appear to be an easy solution to the issues described above without a major change in Medicare policy or the optometric clinical training model. (3)

For further details please see: Development of a New Clinical Training Model.

Footnotes:

(1) Department of Health and Human Services (DHHS) Program Memorandum, AB-01-56, 04/11/2001, Change Request 1498, “Q & A Regarding Payment of Therapy Student Services Under Medicare Part B”

DHHS Medicare Carriers Manual, Transmittal, 1780 Section 15016, C2 Evaluation/Management Service Documentation Provided by Students

(2) Under Medicare policy, optometrists are considered physicians and billing physician as used above refers to licensed optometrists including licensed optometric residents (preceptors).

(3) Mullen, Charles F. “Development of a New Optometric Clinical Training Model”
Journal of Optometric Education, Fall 2006