The U.S. health care system is undergoing a seismic change, and the traditional model of optometric practice must change in order to survive. It is my opinion that the optometrist of the future (today, really), must be able to see more patients per hour, for less cost and with higher quality outcomes. These are the foundational tenets of health care reform as we move from the traditional fee for service model into a bundled model, or ACO model listed as Alternative Payment Models for Value Based Health Care. Fifteen patients per day could easily shift to 30 patients per day, so how you make this move is critical to your long-term success.

If we think about this from a business prospective, that means the traditional optometrist must learn how to delegate more effectively. For the higher volume at less cost with higher quality model to succeed, doctors must allow trained non-OD personnel to do more. Therein lies the potential issues from a coding perspective.

Many optometrists today do delegate and have found some cost efficiencies in doing so, but how does that affect coding?  When delegating, it is important to remember that there are certain rules you have to follow from a medical records and coding perspective in addition to your individual state optometric laws.

The widespread use of electronic medical records (EMRs) has created more uniformity with respect to the patient encounter, as well as a more rigid and exact audit trail that records when someone does anything, so be aware. With respect to the patient encounter, the 920XX codes do not specify by rule who can take the history, perform the refraction, collect data assessing visual function, etc. We do know, however, that the physician must perform the physical examination and is the one who has authority to create a prescription (but not the only one, in some states).

The 992XX codes, however, have a different set of rules. The evaluation and management guidelines stipulate that, while a staff member can record many aspects of the history, the physician must record the history of present illness (HPI) itself. In a typical clinical situation, the staff member must log out of the EMR, and the physician must log in to properly input the HPI. If you are using a scribe, then the notation must be something along the lines of “HPI performed by Dr. Acme, recorded by Jane Doe, scribe.”  

With respect to special ophthalmic testing, many doctors are ordering and performing tests prior to actually seeing the patient. While this may be appropriate for specific types of tests, such as visual fields and OCT, it would not be appropriate for fundus photography (specifically 92250), anterior segment photography (92285) or special anterior segment photography (92286). These types of images require that the physician examine the patient first and determine the medical necessity for the recording of the image before ordering the image, performing the test and interpreting it accordingly. Keep in mind that your digital camera has a time/date stamp associated with every image captured, same as your EMR, so your electronic bread crumb trail is very clear.

Building the optometric practice of the future requires a completely different mindset—one that embraces delegation to overcome the challenges of the faster, cheaper, higher quality mandate. It also raises concerns of making these changes while also considering the rules that are in place. Doing your due diligence with respect to delegation and the medical record requirements prior to making process changes will only help to ensure your success while mitigating associated risk.