Optometrists are well-equipped to diagnose and manage almost any ocular condition that walks through the door, whether simple or complex. However, in the midst of working through the differential diagnosis, it can be easy to forget to handle all of the issues affecting the patient. Often, we make a primary diagnosis, construct a treatment plan and move on—not thinking twice about any possible concomitant conditions. It’s not unusual to deal with a patient whose allergic response is elevated due to a compromised ocular surface and whose contact lens wearing time is reduced or quality of vision is affected—all on the same visit.

Document Everything 

A good example of this is the concurrent presentation of ocular allergies and ocular surface disease (OSD). The symptoms of each can mask one another, confounding the proper diagnosis, treatment and documentation. Moreover, many of these patients are also contact lens wearers, further complicating the already muddled coding picture. 

If your patient presents with a primary complaint associated with either of these two conditions, it is critical to note these issues in the “reason for visit” or “chief complaint” section of the medical record. Once you have completed a thorough systemic and ocular case history, your anterior segment exam notes should reflect your current exam and lid eversion findings and contact lens wear habits, as well as the patient’s lens care products. 

Order your diagnoses based on the patient’s chief complaint and physical findings. Don’t be afraid to map multiple diagnoses to the office visit for appropriate coverage.

The first component of scoring the medical management portion of your E/M visit is tabulating the number of diagnoses and number of treatment options. Here, don’t shortchange yourself by excluding anything, as these factors will also play a role in the remaining sections of the medical decision-making based on additional testing, consultation with other physicians, the acute or chronic aspect of the disease and what was prescribed, if anything.

After the assessment, your plan should clearly state the what, why and when of ongoing care. Be clear and descriptive for each of the conditions diagnosed. For example, use direct statements such as: “patient to RTC in one week for further diagnostic evaluation and follow-up for ocular surface disease and allergic conjunctivitis and potential change of contact lens modality.”  

Done properly, this can then be transposed as the patient’s reason for return visit: “patient returning per doctor-directed orders for further diagnostic evaluation and follow-up for ocular surface disease and allergic conjunctivitis and potential change of contact lens modality. Additional symptoms noted since last visit include…”.  

Greater specificity in the medical record leads to a more clinically appropriate case history, level of physical exam, medical decision making and, ultimately, a more accurate code for the encounter. It also helps you to establish medical necessity for point-of-care clinical lab tests such as osmolarity (CPT 83861) or inflammation (CPT 83516) at the first visit so they can be done prior to the physician seeing the patient on the follow-up. The same goes for any other necessary special ophthalmic procedures. 

Keep in mind that the follow-up schedule may differ for each condition based on the individual. You may follow the dry eye every three to four months, but ocular allergy only every six. Just be sure to note the appropriate frequency of follow-up visits in the record.  

Recording appropriate detail during the entire annual episode of care allows you to ultimately code your procedures and diagnoses properly and map out a clinically relevant and defensible care plan. Don’t forget that concomitant conditions can—and often do—occur in different anatomical regions. You can follow a glaucoma patient who has dry eye and is a contact lens wearer in the very same fashion. 

Your meticulous medical record is where you sort all of this out to ensure the patient is properly managed and you are billing and coding correctly. 

Send your coding questions to [email protected].