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Clinical Care and Practice Advancement
Hospital Privileges Manual

Hospital Privileges Manual: Part V: The Hospital-Based Optometric Examination



PROCEDURES

The examination procedures used by an optometrist in the hospital setting and how that exam is performed can vary widely depending on the individual situation. This depends largely on how integrated into the hospital the optometrist becomes. Optometrists with a full-time staff position may have an office and perform primary care services within the hospital. The services provided might be no different than those in any private office. All needed equipment would likely be provided by and owned by the hospital itself. Optometry in the Department of Veterans Affairs system is the most common example of this type of model.

Most optometrists are less intensely involved in the hospital setting and are called, on an as needed basis, to provide a variety of services. These services might include coverage of the emergency room for eye care, dilated eye examinations of patients with diabetes, preoperative and postoperative evaluation of cataract or refractive surgery patients, and routine eye care to those who are bed bound. Most evaluations within the hospital setting will be chief complaint-oriented and follow the SOAP (Subjective, Objective, Assessment, Plan) format.

One important point to remember is that the provider’s hospital privileges determine what type of services can be provided. Hospitals have a great deal of latitude in the types of services that they may allow a provider to perform. The services approved by the hospital may be quite different than those allowed by state law. As an example, state law may allow the optometrist to treat glaucoma. However, the hospital, in granting privileges, may not approve glaucoma treatment. Therefore, within the hospital, the optometrist may not treat glaucoma. Failure to comply can result in sanctions or loss of hospital privileges. The importance of this point cannot be stressed enough; it is the reason that adequate documentation of the education and experience of the optometrist must be provided upon initial application for privileges.

All hospital medical records are subject to review, and the optometrist’s records will be no exception. The records will be reviewed for clarity and quality of care provided.

EQUIPMENT

The type of equipment needed will vary depending on what services are to be provided and what, if any, equipment the hospital is willing to supply. Under some circumstances the hospital may be willing to set up a complete examination lane or office directly within the hospital. As with any other business venture, the hospital will be looking at a return for their investment. It would be difficult to justify setting up an office if the optometrist is only going to provide care within the hospital one-half day per month. If the optometrist is providing preoperative and postoperative care for cataract or refractive surgery patients, a strong argument could be made that the hospital should provide a slit lamp. The more integrated the optometrist’s practice is in the hospital, the greater the expectation that the hospital will provide some, if not all, of the equipment and support staff needed. This point needs to be addressed in the early stages of negotiations with the hospital administrator.

More often than not, the optometrist will be called on to do evaluations as needed. This usually means bringing portable equipment from the optometrist’s office to the hospital. The equipment needed is essentially the same as required for providing nursing home or other out-of-office services. A variety of hand-held equipment is now available including lensometers, tonometers, slit lamps, autorefractors, and binocular indirect ophthalmoscopes. Following is a list of suggested equipment needed for out-of-office examinations:

  • Direct ophthalmoscope
  • Indirect ophthalmoscope
  • Condensing lenses
  • Hand-held tonometer
  • Hand-held autorefractor
  • Foreign body removal kit
  • Small surgical kit (cilia forceps, lid speculum, etc.)
  • Distance and near acuity charts
  • Trial frames and trial lenses
  • Refracting supplies
  • Pharmaceutical agents
  • Other supplies as needed.

One tip concerning selection of equipment for evaluation within the hospital is to be sure to determine the nature of the evaluation required prior to leaving your office for the hospital. If the optometrist is being called to remove a superficial foreign body, there may be no need to bring equipment other than a foreign body removal kit. By the same token, it can be extremely frustrating to get to the hospital to learn that the patient needs a comprehensive eye examination and not have the appropriate equipment. The simple step of speaking to someone about the nature of the service required can avoid frustration and loss of valuable time. It is best to remember the golden rule of out-of-office care. If you think you might need it, bring it with you.

LABORATORY, IMAGING, AND OTHER DIAGNOSTIC PROCEDURES

The role of a primary care optometrist is to diagnose, treat, and manage conditions of the eye and vision system and be responsible to detect systemic disease that may present itself in the eye. This not only involves traditional procedures such as ophthalmoscopy, slit lamp examination, pupil responses, and refractive measurement, but also may include radiological imaging, microbiological laboratory tests, hematological and blood chemistry testing, and urinalysis. The hospital can play an important role in providing access to many of these needed procedures.

Radiologic imaging includes several different procedures. CT scans, MRIs, x-rays, and ultrasounds are the most useful diagnostic procedures for a primary care optometric practice. CT scans are collimated x-ray beams that allow better contrast and resolution than plain film x-rays. It is the procedure of choice in evaluating blowout fractures and detecting bone fractures and calcification. CT scans are also useful in detection of certain intracranial and orbital tumors.

MRIs utilize a magnetic field and radio frequency waves to analyze structural characteristics. They are best for imaging soft tissue defects found in tumors of the posterior visual pathway, brain stem, and the pituitary gland. MRIs are also used in the diagnosis of multiple sclerosis.

Plain film x-rays are the least expensive imaging technique. Intraocular foreign bodies, trauma to the orbit, and sinusitis are evaluated through this technique.

A Doppler ultrasound examines the integrity of the carotid arteries. A common presenting symptom of optometric patients is an episode of transient ischemic attack or the presence of Hollenhorst plaque. Carotid auscultation performed in the optometric office might indicate a positive bruit and further testing with Doppler may be indicated.

Diagnosis and treatment of external eye disease are large facets of most optometric practices. In most uncomplicated disease situations, a correct diagnosis can be arrived at through history-taking and physical examination. There are clear indications for laboratory testing when additional information is needed to diagnose or manage a patient more effectively. Cytological testing examines the body’s cellular response to disease. Specific cytological stains (e.g., Wright’s, Giemsa, and Papanicolaou) identify inflammatory and neoplastic cells as well as inclusion bodies. Microbiological testing by smears, scrapes, and impressions helps identify specific pathogens and isolates their sensitivity to specific antibiotics. Indications for laboratory testing include ulcerative keratitis, severe or nonresponsive conjunctivitis, cellulitis, toxic reactions, and dacryocystitis.

Hematological testing is used routinely in medical practice. It is useful in optometric practice, as well, to screen for systemic disease, establish baseline information, monitor patients when prescribing certain medications, and establish differential diagnosis. Tests such as complete blood count (CBC) and erythrocyte sedimentation rate (ESR) are helpful in identifying inflammations and infections, anemia, and collagen disorders. Studies of blood chemistry are useful in identifying diabetes, hyperlipidemia, hyperthyroidism, leukemia, Lyme disease, toxoplasmosis, sarcoidosis, rheumatoid arthritis, and other systemic diseases that affect the eye. Optometric patients presenting with eye symptoms suggestive of these diseases or diagnosis of uveitis, retinal hemorrhage, dry eye, proptosis, etc., may need blood testing. In addition, certain medications such as acetazolamide require blood tests to establish potassium levels and rule out kidney disease before initiating therapy.

Urinalysis is another laboratory test that may be useful in optometric practice. Analysis of ph, glucose, ketone, proteins, blood, and other urine components aid in the diagnosis of many conditions. Examples include galactosemia cataracts, diabetes, ectopia lentis, and nutritional and toxic amblyopia. Used by itself or as an adjunct to other laboratory tests, urinalysis plays a role in optometric care.

CHARTING

Hospital medical records traditionally have been maintained in bound ring file folders. However, many settings are now utilizing electronic medical records. They will be found at nursing stations throughout the hospital. The patient’s name, date of birth, room number, hospital identification number, or other identifiers are usually found on the end section of the folder. The top cover of the folder will list any alerts associated with the patient. These alerts might include: name alert (two persons on the same ward with same/similar names), specific drug allergies, infectious disease alert (TB, Hepatitis A, HIV positive), or infection control alert (requires gown, gloves, mask, booties to enter room).

The medical record is divided into numerous sections typically including: demographic data, discharge summary, admitting history and physical (H & P), physician progress notes, consultations, pharmacy notes, dietary notes, laboratory, pathology, and x-ray/radiology reports, operative reports, physician orders, and nursing notes. Individual services (e.g., cardiology, pulmonary, GI) may also have their own sections. All appropriate sections should be reviewed prior to evaluation of the patient so that the patient’s current status may be determined.

  • The admitting history will often be combined with the demographic section at the beginning of the chart. This section will include the initial physical evaluation (why the patient was admitted) and the patient’s previous medical history.

  • The physician progress notes contain the attending physician’s examination notes for the patient. This section may also include consultation, pharmacy, and dietary notes.

  • Laboratory, pathology, and x-ray/radiology reports are included.

  • Operative reports contain the surgeon’s dictated notes concerning the examination and the procedures performed during surgery.  For example, the description of the type of cataract surgery performed would be found here.

  • The physicians’ orders section of the chart is essentially the prescription pad within the hospital record. Medications being ordered, requests for laboratory and other tests, dietary, and other procedures (e.g., needs dilated eye exam) will be charted in this section. The most up-to-date medications taken while in the hospital will be listed in this section and may be different from those in the admitting history.

  • Nursing notes contain nurses’ charting of their interactions with the patient. This will often include information on when complaints were first noticed by the nursing staff (e.g., patient has red eye, complains of blurred vision).

In most cases, the optometrist will chart within the consultation section of the medical record. Many hospitals will have specific preprinted consultation forms that are to be filled out and placed within the consultation section of the medical record. In other cases, a consultation note may be written in the physicians’ progress note section. Notes from the examination or procedure performed must be kept in the patient’s medical record. A copy (photocopy or carbon) of the examination form should be retained in the optometrist’s office files. If medications are to be ordered, the optometrist should chart this in the physicians’ orders section.

Charting procedures may vary from one hospital to another. The provider may be required to undergo security checks and training to access the electronic medical records. It may be helpful to discuss charting with the Medical Record Department staff shortly after your staff appointment.

An examination finding, medication orders, or requests for action (e.g., lab test or procedure performed) that need immediate attention should be “flagged.” This is typically done by folding the examination form so that a portion sticks out of the medical record. This is a universal sign that something in the chart needs to be brought to the nurse’s and attending physician’s attention.

Abbreviations, in general, should be avoided when charting. They can lead to confusion among providers of different disciplines. They are, however, a fact of life in the hospital setting. The list contained in Appendix C is by no means comprehensive but is a list of commonly used abbreviations in the hospital setting. Since each hospital may have its own approved abbreviation list, it is important the provider confirm the hospital’s standardized list before charting begins.

PROCEDURE CODING

Reimbursement for optometric care begins with proper coding of procedures and services and proper coding of the diagnosis. The basis for service coding is the Physician’s Current Procedural Terminology (CPT) of the American Medical Association. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the basis of diagnosis coding. The provider should be familiar with these publications in their entirety before beginning to use them. The explanations that follow are intended to explain specific hospital coding issues. Please refer to copies of CPT and ICD-9-CM manuals for a complete explanation of these coding systems.*


* Coding is constantly changing and is subject to local variations and modifications. Please refer to specific carrier policies and current year coding manuals for specifics to your practice. Proper patient record keeping procedures must be followed to document utilization of selected codes.

Evaluation and Management (E/M) Services

Evaluation and Management (E/M) Service codes may be used for services rendered by optometrists in a hospital setting. These codes provide a classification system based on the key components of history, examination, and medical decision making. Additionally, counseling, coordination of care, and the nature of the presenting problem are contributory factors in selecting the appropriate E/M level of care. The final component, time, is considered as the key component only when counseling and/or coordination of care involves more than 50 percent of the patient/optometrist encounter. E/M codes are classified in five levels of care, with the appropriate classification dependent on very specific criteria involving history, examination, and medical decision making. The patient record must document these components to justify the code selection. Proper identification of place of service, dates of service, and referring physician UPIN numbers must accompany the claim for proper reimbursement.

E/M coding does have a classification of new and established patients. A new patient is one who has not received any professional services from the optometrist within the past three years. No distinction is made for new and established patients in the emergency department.

E/M codes also have category and subcategory classifications. For hospital practice these include outpatient and inpatient services, consultations, and emergency department services (Table 1).5

Office or other outpatient services codes are to be used if a patient is examined as a hospital outpatient (this may include examination in a holding area of the hospital) or in an ambulatory care facility. Five levels of care are recognized in each of the two subcategories. If the patient is admitted to the hospital, hospital inpatient services – subsequent care codes are to be used. Three levels of care are recognized in the subsequent hospital care subcategory. (Table 1)

Consultations are services provided by an optometrist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source. The request must be documented in the patient’s medical record. The consultant’s opinion and any services ordered or performed must also be documented in the medical record and communicated to the requesting physician. When billing consultation codes, you must have documentation in the patient’s record that all qualifying criteria have been met. Five levels of care are recognized in the initial inpatient consultations subcategory and three levels of care are recognized in the follow-up inpatient consultations subcategory.

Confirmatory consultations are used to report services provided to patients when the consulting optometrist is aware of the confirmatory nature of the opinion sought (e.g., a second opinion confirming a cataract). Confirmatory consultations may be provided in any setting including the hospital. Five levels of care are recognized in this subcategory.

Emergency Department Services are used to report services provided in the hospital emergency department. An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. Care must be available 24 hours a day.

Table 1
Evaluation and Management Service Codes
Category of Service CPT Code
Office or Other Outpatient Services
New patient
Established Patient
99201-99205
99211-99215
Hospital Inpatient Services
Subsequent Hospital Care 99231-99233
Consultations
Initial Inpatient Consultations
Follow-up Inpatient Consultations
Confirmatory Consultations
99251-99255
99261-99263
99271-99275
Emergency Department Services 99281-99288

Ophthalmological Services

General Ophthalmological Services codes are also appropriate codes for reporting hospital examinations; place of service, of course, must be identified as the hospital. Special Ophthalmological Services codes (e.g., refraction, gonioscopy, visual fields, serial tonometry services/procedures) may be used. Ophthalmoscopy, other specialized services, contact lens and spectacle services, and appropriate surgical codes may also be used (Table 2).5 A complete listing of these services may be found in the CPT manual and in Codes for Optometry (published by AOA) which includes the CPT minibook containing codes for ophthalmology.

Table 2
Ophthalmological Services
Service CPT Code
General Ophthalmological Services
Intermediate, new patient
Intermediate, established patient
Comprehensive, new patient
Comprehensive, established patient
92002
92012
92004
92014
Special Ophthalmological Services 92015-92140
Ophthalmoscopy 92225-92260
Other Specialized Services 92265-92287
Contact Lens Services 92310-92326
Ocular Prosthetics 92330-92335
Spectacle Services 92340-92371
Supply of Materials 92390-92396
Unlisted Ophthalmological Service or Procedure 92499

The appropriate fee is determined by each individual optometrist. Actual reimbursement, of course, is determined by each individual third party payer. This may vary by payer and region. Relative value units (RVUs) are specific to services. Table 35, 6 contains RVUs for some commonly performed hospital services. The RVU can be multiplied by a specific dollar amount (i.e., conversion factor) to set an appropriate fee level or to determine a reimbursement amount. RVUs for particular CPT E/M codes may change each year. You should check the yearly Medicare Fee Schedule (MFS) that the Centers for Medicare and Medicaid Services publishes for the most up-to-date information regarding RVUs.


   
Table 3
Relative Value Units for Hospital Services
(These are examples only and may change yearly. Please check the current
Medicare Fee Schedule for the most up-to-date RVUs.)

CPT E/M Codes

RVUs

Office Evaluation & Management
99201 0.63
99202 1.25
99203 1.91
99211 0.24
99212 0.63
99213 0.91

Hospital Inpatient – Subsequent Care
99231 0.89
99232 1.47
99233 2.09

Office Consultations
99241 0.90
99242 1.85
99243 2.48

Initial Inpatient Consultation
99251 0.95
99252 1.91
99253 2.61

Confirmatory Consultation
99271 0.64
99272 1.22
99273 1.71

Emergency Department Services
99281 0.44
99282 0.73
99283 1.64

Intermediate Ophthalmology
92002 1.25
92012 0.98

Comprehensive Ophthalmology
92004 2.40
92014 1.60

Extended Ophthalmoscopy
92225 0.55

Foreign Body Removal Corneal with Slit Lamp
65222 1.25
 

ADMISSIONS AND DIAGNOSTIC RELATED GROUPS (DRGS)

Hospital patient admissions may be classified into diagnostic related groups (DRGs) for purposes of determining payment under the prospective payment system. Cases are classified into surgical or medical DRGs using ICD-9-CM diagnosis and procedure codes. Classification is based on principal diagnosis, up to eight additional diagnoses (complications or comorbidities [CC]), and up to six operating room (OR) procedures performed during the stay, as well as age, sex, and discharge status of the patient.  Nonsurgical procedures or minor surgical procedures, not performed in an operating room, generally do not affect DRG classification.7  Table 4 contains a list of eye-related medical DRGs.7

  
Table 4
Eye-Related DRGs
DRG # Diagnostic Related Group
43 Hyphema
44 Acute major eye infections
45 Neurological eye disorders
46 Other disorders of the eye age >17 with CC
47 Other disorders of the eye age >17 without CC
48 Other disorders of the eye age 0-17
462 Rehabilitation

Hospital admissions for eye-related problems are quite rare regardless of provider type. Less than 0.4 percent of all hospital discharges have eye-related DRGs. However, there may be circumstances in which optometrists may need to admit patients (e.g., conditions such as serious eye infections, hyphema, or some neurological eye disorders). Optometrists who currently have admitting privileges should admit in conjunction with family physicians or internists. This protocol is patterned after podiatrists who have admitting privileges.

The DRGs under which optometrists might admit include eye-related DRGs 43-48. Optometrists involved in low vision rehabilitation could potentially admit patients under DRG 462. The traditional services of refraction, binocular vision evaluation, and spectacle and contact lens fitting are not covered under DRGs and admission for these problems is not appropriate. These services may be provided during the course of a hospital stay for a non-related illness.