The New England Eye Institute (NEEI) is the Patient Care and Clinical Education Subsidiary of the New England College of Optometry. Click here for The NEEI Comprehensive Eye Exam Form (PDF)
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:
- 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.
- General medical observation
- External ophthalmic examination
- Ophthalmoscopic examination
- Gross assessment of visual fields
- Sensorimotor assessment
Optional features of a Medicare compliant examination include:
- Dilated ophthalmoscopic examination
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 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.
Charles F. Mullen