As optometry becomes a bigger player in the medical eye care field, our risk of audit increases commensurately. So, while being more profitable is good, being safe is better. We can accomplish both things simultaneously. To do so, lets review two key concepts that every office must employ on a daily basis to keep safe in any post-payment review or audit: medical necessity and chief complaint. These are the fundamentals that every office must not only understand, but also strictly adhere to in order to be compliant.


Medical Necessity

The Centers for Medicare & Medicaid Services (CMS) defines medical necessity as: Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are provided for the diagnosis, direct care and treatment of your medical condition; meet the standards of good medical practice in the local area; and arent mainly for the convenience of you or your doctor.1 So, keep in mind that you must demonstrate that the procedure or test is needed for the diagnosis and treatment of the patient in the medical record.

Remember, the medical record is like a storybookit has a beginning, a middle and an end. As the physician, you must tell the story of the patients encounter, including your reasoning or thought process for what you are doing. If you believe that a procedure is needed or necessary to aid you in the diagnosis or treatment, tell the record of why you felt that way. It is your only defense in a post-payment review process. Tell the record of not only what you are doing for the patient, but also tell why you are doing it. If you follow this guideline, youll have a much better chance of defending your reasoning at some point in the future when your memory isnt as good as it should be.


Chief Complaint

Heres how CMS explains the chief complaint: The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patients condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physicians services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.2

Simply put, the chief complaint is the very foundation for determining whether an office visit or procedure can be billed to a medical carrier. Keep this in mind as you are teaching or instructing your technicians about the finer points of taking a case history. Take heed in not misrepresenting or manufacturing a reason for the patient to be in your office. If the patient is there for an annual examination (by recall) or just because he or she wants glasses, typically the visit would not be covered unless your medical record, from the previous encounter, spelled out why the patient is to be there at a specific interval.


Keeping these two key concepts fresh in your mind and in practice will allow you to provide medical eye care services to your patients with their best interests at heart, and will give you the peace of mind to sleep well at night. Remember, increased profitability from providing medical eye care and safety are not mutually exclusive goals. In fact, when done correctly, your practice can offer a higher level of services to your patients and enjoy a better bottom line.

Please send your comments to

Clinical Coding Committee

John Rumpakis, O.D., M.B.A., Clinical Coding Editor

Joe DeLoach, O.D.

David Mills, O.D., M.B.A.

Laurie Sorrenson, O.D.
Rebecca Wartman, O.D.


1. Centers for Medicare & Medicaid Services Web site. Glossary. Available at: (accessed May 28, 2009).

2. Centers for Medicare & Medicaid Services. The Carriers Manual, Part 3: Claims Process, Ch. 2: Coverage and Limitations, 2320: Routine Services and Appliances: 2-122.



Vol. No: 146:06Issue: 6/15/2009