Wiki Eye Exam Documentation

[reinholds@qlarant.com]

I conduct medical record reviews (chart reviews) for an External Quality Review Organization. Their Encounter Data Validation task requires providers to submit records and my job is to check and make sure the coding/documentation for the encounter matches the claim that was sent to the MCO. Vision exams seem to be a challenge for me. Most of all the reviews I've done have V codes for the purchase of glasses/frames, and the type of glasses/lenses. However, there is no documentation/proof of purchase of said glasses. I just need to know if the proof of purchase needs to be included with the encounter documentation. So far, ALL reviews I have done have the V codes for glasses/frames purchase (V2020, V2100, V2101, etc.), but no proof of purchase documentation. Is this something that doesn't need documentation?

Thank you in advance for your help and assistance!

Suzanne

 

[Kristen Bensel]

What exactly are you meaning for proof of purchase documentation- like an invoice or just a note? I work for a multi-specialty clinic and our EHR is not specialty specific, so we have to get creative sometimes with how certain things are captured. Glasses are one of those things.

We have the opticians who are helping patients select frames/lens document a note that we have created that will guide the optician to remember to document all specifics about each pair of glasses that are ordered for a patient- frame number, color, lens coatings ect.. The template includes the V codes along with amounts charged. (As I said, we have to do this manually because our system isn't an optometry specific EHR.) Once they have filled it out, that is used to help support what is billed to the insurance or to the patient if they are self pay. This note is also used as a running record for that specific pair of glasses. So when the glasses are dispensed it is noted if they are fitted to the patient at the time, or if it wasn't the patient who picked them up, then who received them on their behalf. And if any warranty work is done on the glasses, that is also noted as an addendum to the original note to keep a running history of that one set of glasses.

We chose to do it this way to cover our optometry staff and the patient if questions ever come up. However, I would think it would be standard for it to be documented somewhere in the record of what was ordered for the patient. Maybe it is captured in another area of the EHR?