Comprehensive eye care is super important. Unless you live near a major metropolitan area, you may not have access to different subspecialties. General ophthalmologists may have to don many hats to ensure that their patients receive the care that they need. Primary ophthalmologists will perform emergency lasers for glaucoma or retina patients from time to time, as well as the rare temporal artery biopsy. Comprehensive eye care isn’t just refractions and rainbows.
Often, people are referred to ophthalmology by optometrists or their primary care physicians, but many patients skip those steps and start their eye health journey with a general ophthalmologist. As the front line of defense in this person’s eye care, paying attention to their history is important.
Electronic medical record systems (and paper charts) al have a different way of entering information but all of the information required is the same across the board*: allergies, medications, known diagnoses, previous surgeries, chief complaint (CC) and history of present illness (HPI). Most systems let you expand your CC into a note and, unless your doctor is completely against it, you should briefly enter some pertinent info there.
Medicare, which makes the general rules that everyone follows in healthcare, requires certain data for different levels of care and reimbursement. Some practices require height and weight, some don’t. Some require blood pressure and pulse, others don’t unless performing a procedure. Find out what you need to have in your work up from management and make sure you hit those markers, otherwise your practice can take a financial hit and they’ll come looking for the employee who is preventing the office from getting paid.
Fun fact (but not really): Having a chief complaint like “comprehensive eye exam” or “cataract evaluation” isn’t enough information for the insurance companies, so they can deny payment to your office. CC’s should always have some sort of modifier and it is best to use your patient’s own words (example: cataract evaluation; “my vision is getting cloudy”).
Now, when I said “modifier”, I don’t mean the CPT code required for proper billing. I meant the term in the literal sense—the different qualities that modify the patient’s chief complaint. These are kind of like the how, what, where, when and why of their main eye issue. Most exams with a general ophthalmologist are routine and annual checks, so basic info is usually adequate for these patients and can look like this:
Patient presents for an annual comprehensive eye exam; she states that her vision has slightly worsened at near since her last visit on MM/DD/YYYY. She denies flashes, floaters and eye pain at this time.
If your patient wears glasses, take note of when their last pair was made and document the prescription in the proper area of the chart.
*Most systems allow for much more info, like family history and sexual history. You should always fill out what your practice requires and want your physician wants.