Vision Specialists Of Michigan

Debby Feinberg, O.D. Paul C. Feinberg, O.D Morrie Dubin, O.D. MaryJo Ference O.D.

Neurovisual Optometric Scribe

Handbook

Edited: August 23, 2013

Created by: Narine Shirvanian

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Table of Context

Section Page

What is a scribe? 3Understanding HIPPA 3Scribing in Compulink

Chief Complaint 4Hist/Hist cont 4VHSQ 6Medication 6VH Binoc 6Ant/Post 7Refraction 7Plan 9CL Diag/CL Check 10Codes 2 & Billing 10Test Sum 11Documents 11

Contact Lens Evaluation 12NV Progress Re-evaluations (Rx Checks) 13Writing Letters 14

Faxing Signing OffMarking DoneScanning

Written Paper Work 16Staying Organized 16Green Sheets 17Letter templates 18Supplemental Materials (From Angie) 23

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What is a Scribe?

At Vision Specialists of Michigan, a scribe is responsible for entering every aspect of a patient’s relevant medical history, both in the exam room and out. As a scribe, the majority of your work will involve documenting exam data, live into the Electronic Medical Record (EMR). In addition, you will be entering patient billing charges, writing doctor report request letters, summarizing miscellaneous patient-doctor communications (outside the office), and keeping track of patient exam forms and necessary documents. You will experience firsthand patient contact, along with a broad knowledge of the visual system and its influence on various body systems.

While the day’s schedule is booked in advance, it is always subject to change. Therefore, a scribe must be prepared to evolve while, at the same time, remaining calm in a possibly hectic environment. Since we are dealing with patients’ medical records, it is crucial to remain organized in an effort to eliminate any misplacing of documents.

Even though you will be working one-on-one with your designated doctor, all of the scribes are part of a team who intertwine and work together. Every scribe must take responsibility for entering their patient’s information, however, if in need of help, a fellow scribe will always be ready with support. So don’t hesitate to ask!

Quick thoughts about Understanding HIPPA

It is crucial to remember, while working alongside the doctor you are subject to the same patient-physician confidentiality agreement. Therefore, any information mentioned during the exam must remain within the records for that exam. Similarly, it is prohibited to remove any patient files – including exam forms, visual fields, lens prescriptions, etc. - from the office, even if intended to be used for work purposes. If you find you were unable to finish scribing some aspect of a patient’s evaluation by the end of the day, you must leave all the records in the office and continue working on them the following day.

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Scribing in Compulink

Usually, by the time a patient gets to the exam room they have already undergone a list of screening tests along with filling out an electronic Web Registrations, and any other necessary paperwork. They should already have had their picture taken, as well has been assigned a layout in their medical record.

Should for some reason, your patient reach the exam room without having a layout open, you must open one by clicking ADD (top left corner) and choosing the appropriate layout in regards to their visit.

Our patients are classified into the following groups:

Initial – New to the officeAnnual – returning patientFollow-up – having had an appointment in the past 6 months.

Within these classifications, they’ll be either Neurovisual (~90%) or Standard Optimetric (10%). Our neurovisual patients are further separated into standard or auto patients (auto patients have suffered an auto accident and receive auto insurance coverage – these patients require very detailed and specific documentation). After choosing the appropriate layout, you are ready to begin entering exam information.

Working by Tabs

Summary

The Summary tab is very appropriately named, in that it provides an overview of the patient’s entire record. There is no information to be entered on this tab; use it as a point of reference only.

Chief Complaint

This section contains information you must gather prior to the start of the exam. Make note that the correct exam date is listed in the box at the top left corner. Then proceed to filling in every slot in the purple colored box.

Helpful Hints:

- If they are accompanied by multiple people including a case manager, the case manager is the most important, and must be named in the appropriate box

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- If they are alone, enter “Self”, and “N/A” in the slot labeled Relationship.- You must enter your name (the scribe) in the slot labeled Info Provided By- If no Referring doctor, fill in how they found/heard about the office, Ex: internet, news

article, Friend (with friend’s name)…- Reason for Today’s Exam has a drop box, but can also be typed in. Often time, this box

will be filled in by the patient through their Web registration, but it isn’t correct. You must make sure to classify it as one of the following:

o NV Initial/New; NV Follow Up; NV annual; Regular exam New; Regular exam Annual; NV Progress Re-evaluation (replacing Prescription Check); CL check; CL Follow Up; CL evaluation

o If some other type of visit, review with doctor and billing department

In the Complaint box, choose the primary complaint, and proceed to type the entire case history in the space to the right. Make sure to SAVE your work periodically!!!

Our office deals with difficult cases which accompany even more difficult insurance debates. In an effort to eliminate any insurance disputes of charges, we must take very detailed case histories. For information regarding case history do’s and don’ts, see supplemental materials DOCTORS NOTES. ** Right click spell ckeck make sure everything is spelled correctly**

History

This tab reflects all of the symptoms filled out by the patient on their Wed registration. You have a few things to do on this tab, but I promise, just a few.

1. Ask the patient if they currently drive during the day and at night (check/don’t check the appropriate boxes).

2. Fill out the General Status slota. If initial/annual exam: choose A – all systems reviewed & negative unless…b. If follow-up: choose B – Reviewed since last visit

3. For a follow-up visit, the boxes will not propagate automatically. Right click on green space and choose: Update from last value.

**MAKE SURE HISTORY/SYMPTOMS ARE FILLED IN – VERY IMPORTANT**

History Continued

Since we are so in depth, our medical history couldn’t fit in one tab. This continuation tab has two major sections: social history and tobacco status.

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- If initial/annual visit, you must ask the patient this info prior to starting the exam.- If Follow up visit, Right click and choose: Update from last value.

Also, if the patient had any kind of ocular operation (cataract, strabismus, glaucoma, LASIK…) you would enter the information regarding those surgeries in the Ocular Surgery section.

VHSQ

This tab contains the patient’s response to the VHSQ questionnaire, along with SSI values. Info from this tab is mainly used as reference, and requires no “data entry” on the scribes behalf.

Medication

This tab is very self explanatory but very important. Again, all medication and allergy histories must be asked during every visit, and prior to beginning the exam.

- Once you have entered the medications and allergies click Reviewed OK - If no meds/allergies, click either No Meds Reviewed OK or

NKDAReviewed OK

VH Binoc

This tab marks the beginning of the doctors testing. All the information on this tab will also be written down by the doctor, but if you miss any information don’t hesitate to ask the doctor to repeat a value. In general, all the tests on this page must be performed. There will be instance when a doctor only performs one or a couple. In that case, you must state, IN the NOTES box (to the right), why a certain test was not performed. If you are unsure why, ask your doctor.

Ex: “light box, red lens test, and NPC were not performed due to patients sensitivity. We did not perform these tests in an effort to keep from increasing his current symptoms”.

To fill EOM/Pupils/Visual Fields: Right click encounter favorites. This will propagate the tabs with “standard” values. It is good to start with the standard values, and change them if the doctor mentions a change. Otherwise keep standard values.

- Often times, the doctor will ask the patient to fill out another type of questionnaire. You will add the score from this questionnaire in the notes section.

o Ex: “SSCD questionnaire: 4/14” “dysautonomia questionnaire: 7/13”- Often when ranking their headache symptom severity, patients will be asked to describe

the location of their headaches; add the HA location to the notes sectiono Ex: “HA location: top and back of head, temples”.

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- Any other comments you deem significant (placement of head, turning in of toes, general body posture, additional testing) should be added to the notes section.

o Ex: “ Light box measured w/out Rx: Vertical 3 UP OD; Horizontal 0.25 IN OU”

** When in doubt, add it to the NOTES **

Ant/Post

This tab documents the findings from the slit lamp. To begin with you must set the default values: Right click Encounter Favorites choose based on visit (either initial/annual or F/U)

Once you have filled in the default you can then go and make changes according to the doctors findings. If the doctor comments on things not found, or unable to fit completely in the present boxes, fill out the boxed to the best of your ability, and write everything they found in the notes section at the top right corner.

- Ex: “2+ cataract, 1.5+ cloudiness. Arcus Sinilus around cornea. 0.5+ injection”

The top portion (ANT) is measured with a slit lamp (microscope). The bottom half (POST) is measured either free-hand w/ophthalmoscope, or through funuds/retinal photo assessment.

During this time, the doctor will ask to see the patients retinal photos and visual fields. They can be found under the Test Sum tab – see Test Sum section for more information on opening photos.

Any comment made regarding the fundus photos must be added in the lower portion of the page, and in the lower box on the right hand side.

** The computer automatically checks Dilated, located towards the middle of the page. Make sure to un-check this box, since we do not perform dilated exams. **

Follow up exams will only perform an ANT health check – no posterior (and therefore usually no retinal/visual fields will be performed for follow-up progress evaluations).

Refraction

This tab contains the patient’s lens prescriptions. In general, a patient will have 3 separate scripts per visit, with one finalized script which will be ordered.

1. Automated: this is an automated reading of the eye that is taken during screening. This value should be entered, or on the written exam form, ready to be entered.

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2. Subjective: measurement of the raw prescription following a refraction, but before trial-framing. Patients will often trial-frame this Rx before finalization.

3. Final Rx: there are many types of final Rx’s. Depending on the patient’s need and the doctors recommendation a patient may have a combination of myopic/hyperopic/astigmatic corrections, with bifocal power, and vertical/horizontal prism. They may order a lined or progressive bifocal, a pair for near/far, both, computer lenses, sports glasses… the possibilities are endless.

*enter the prescription carefully – incorrectly lenses are costly to the company *

Once you have copied down the lens values, you must decide how that scrip gets classified by using the drop boxes to the right. Only a finalized Rx must fill out all five boxes.

** Make sure to check Make available for Optical when filling out a Finalized Rx, in order to allow the prescription to be ordered by the opticians.

Helpful Hints:

- You can print any prescription by clicking PRINT at the end of the Rx (right side). - CYL is always a (-) value- ADD doesn’t contain a power in front of it. Don’t write: +2.00; Write: 2.00 only- If you have a CYL you must have an AXIS; these two numbers coincide.

For a Follow up progress evaluation, or annual visit, you will often check Visual Acuities (VA) with the patient’s current Rx. The computer won’t let you bounce between different exam dates, therefore you should write the VA in the NOTES section of the Automated script.

Ex: If the patient came for a follow up visit on 8/1/13 wearing his glasses from 7/1/13, enter the VA in the NOTES section as such

VA with 7/1/13 Rx: Distance: OD 20/___ OS 20/___ Near: OD 20/___ OS 20/ ___

Below the Prescription section is the table for VonGrafe Testing and Cross Cylinder. Both of these tests are performed behind the instrument, and in sequence.

Below the VonGrafe table is a section highlighted in green which reads the patient’s Keratomotry (K) Values. These values will usually be filled in during the patient screening, however, sometimes will have to be entered by hand (from the slip printed from the automated machine).

Doctors may also perform a near Vergence test located to the right of the Cross Cylinder table.

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Plan

The plan tab contains multiple important sections, which summarize the exam findings, diagnoses, future plans, following appointments, and final assessments. Per the prescribing doctor, the patient will be diagnosed with a combination of optical and medical diagnoses. Some the diagnoses are present and clickable, others may have to be typed in. Either way, once the list of diagnoses is determined, they must be ranked in order of importance, and assigned an eye (OD – right, OS – left, OU – both).

- For a list of diagnoses and complementary codes – see supplemental materials: Medical Diagnosis codes used to document Neurovisual Exam

- VH and SOP are always ranked #1; followed by all medical diagnoses (headache, dizziness…); followed by visual diagnoses (myopia, hyperopia, astigmatism, presbyopia).

Once you have ranked your diagnoses, you must add an assessment and findings to only the #1 ranked diagnoses (either VH or SOP – if neither than move down to other visual misalignments – exophora, esotropia…).

Assessment Box:

- Include all trailed lenses and results of each trial. Did they respond well, did they reject.- Include how they responded to the final Rx, if there is one. If not, explain why you will

not be finalizing an Rx at this time.- Include any Dr. referrals/consulations- Include any specific patient recommendations

o Ex:” we are recommending that she order a near distance prescription to be worn during reading and other near distance tasks”.

o Ex: “it is being recommended that she wean off of xanax, in order to have a better response to the prism glasses”. ** right click spell ckeck make sure everything is spelled correctly**

Findings Box:

- Everything in this box is generated from a pre-set list of optionso Double click click on all necessary boxed save, and they will all fill in

automatically. You may have to make slight changes to the preset descriptions.

It is very important to keep track of the time spent with each patient, and enter the correct value in the time box to the right of the Findings. Based on the time spent with the patient,

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determine exam complexity. For guidelines in determining exam complexity and accompanying codes see supplemental material: Grand Chart, Code Break Down, and High vs. Moderate.

Next Appointment

On this same tab, you must also determine the next appointment time. There are 4 present options. You must choose one of these options. However, if you find your doctor has requested the patient to come back for an appointment that doesn’t correspond to one of the four options, choose the closes option and then edit the date. Make sure to add notes in the notes section if you are changing the date.

- Ex: 3 weeks request: choose two week VH follow up, change date on calendar, and write “patient will return for a 3 week F/U per Dr. _______”.

- Ex: post consult: choose one month, and write in notes section: “the patient will return for a progress evaluation post SSCD evaluation by Dr. John Doe”.

Educational Packets

For first time Prism Wearers: we must supply them with an information pack regarding visual misalignment and prism. This is done in the Education section.

Click on VH folder; also pick VH folder from the Drop box, and print from the delivery methods. The same format is followed for first time SSCD, MAV, or Dysautonomia packet recipients.

*only for first time recipients (mainly initial visits); don’t need to repeat yearly.

CL Diag/CL Check

These tabs are used for a contact lens exam. We utilize the CL Diag tab more, because this is where we would enter a contact lens script. See section below on Contact lens Evaluation for more information regarding these couple tabs.

Contact lenses can be tricky, so always ask for clarification if you are confused in any way. Often times patients try on multiple contact lens trials, and each trial must be entered and commented on (fit, comfort…). When in doubt, ASK!

Codes 2

This tab is the first step in billing. It allows us to choose which charges will be added to the patient’s ledger. Along with choosing the appropriate codes (varying from visit to visit), we must choose an Office Code and double check to make sure the Reason for today’s visit is

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correct. * remember, this was originally correction on the Chief Complaint tab (purple box). You can fix it on either tab, and it will automatically be corrected on both.

For information regarding guidelines to choosing the proper codes, again see supplemental material: Grand Chart, Code Break Down, and High vs. Moderate.

Test Sum

This tab with include the results of the Sensorimotor Exam, as well as the Fundus and Visual field images.

Sensorimotor Testing

Click on sensorimotor to generate a new test. Once generated, you can add the preset results by Right clicking the Findings box Note Lookup choose one of four options (from long list).

Findingso New Patient – Prism trial Improvedo New Patient – Prism trial Not Improvedo Old Patient – need Change of Prismo Old Patient – No change of Prism

Managemento New Patient – Prism will be Rx’edo New Patient – Prism will not be Rx’edo Old Pt – Prism Rx Updatedo Old Pt – no change in current Prism Rx

__________________________________________________________________________

Fundus photos and visual fields can be either double clicked/right click View image full screen, or Fundus Photos opened via an external cite on the desk top. Either way, once the doctor has reviewed and commented on both images, you must mark reviewed by entering date and doctors initials, along with jotting down the doctors comments in the findings section.

Once you have including the findings in this section, you must also copy/past the same findings in the Ant/Post tab, lower Posterior section Note box. If the doctor finds abnormalities in the patient’s images and would like to refer them for a consult, you must enter this info in the Management box below Findings, and also add the consult referral to the Assessment box in the Plan Tab, and a shorter summary in the Plan box of the Plan Tab.

Documents

This tab is strictly used to store patient’s letter requests. See below for information regarding how to write a letter. In that section, you will also find instructions on how and where to save

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your letters, and how to export them as PDFs to your desktop in order to Input the file in the Documents Tab.

To save a letter to the Documents tab:

- Enter type of exam in Category box (initial, F/U #1, Annual, F/U #4)- Enter date of exam in Description Box (8-23-13)- Right click import Choose PDF files from desktop double click desire file save

Tech - This tab is used by the opticians during screening, and requires no input by the scribes.

At the end of the exam (once you have finished entering all the info, but before the exam form reaches the opticians) you must perform some final steps.

1. Print the CCD: Print CCD (don’t actually print it, just pull it up on your screen).2. Pull through the charges: Charges Post Save all the separate charges

a. First box: Doctor, Second Box: blank3. Sign off your initials and the date you entered the information into the EMR4. Gather the names of the patients you entered on a sheet of paper

a. This list will be given to Dr. Debby, who will review every record and perform a final sign off

5. Log IN under your name and open up each patient’s record to ensure you were the one entering the information

6. Once the patients chart is returned to you, place it in a bit until Dr. Debby has signed off.7. Every couple day, go through the bin and mark DONE (with highlighter) on those exams

that Dr. Debby has officially signed off on. a. Ex: Done 8-23-13 DLF

8. Once an exam form is marked DONE, it then transfers to a bin in the middle room, where it awaits to be scanned into the patient’s EMR.

Contact Lens Evaluations

Contact lens evaluations are very different compared to neurovisual and even standard optimetric visits. Many of the tabs will not require the standard information to be entered, however, some info will is still required.

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- The first 5 tabs (Chief Comp, Hist, Hist cont, VHSQ-Adu, Medication) will be entered the exact same way.

- VH Binoc: usually, there will be no binocular testing. In these instances, you will make note of the reason why in the NOTES box. Example statement: “Contact lens evaluation/follow-up/check – therefore no binocular testing was not performed”.

- Sometimes, with prism contact, their alignment may be measured. This might include a light box exam or red lens test, NPC, or a combination of a few tests. In these instances:

o Enter the test findingso Make note of the tests not measured in the Notes box; Example: “Contact lens

evaluation/follow-up/check – therefore did not perform the following tests: Hirshberg test, Double Maddox Rod, EOM…”.

- Make similar notes in Ant/Pos Tab.- Duplicate last visit in Plan tab, and indicate exam findings like normal.- CL Diagnosis is the main tab for this visit. Record all contact lens information including

trial contacts, fit, comfort, over-refraction, full script, order info, and make available for order.

- CL Check used for contact lens check exam; document how the patient is doing in a specific contact lens trial.

- See biling information for specific codes- No sensory motor testing during contact lens exams – leave tab blank.

NV Progress Re-evaluations (Rx Checks)

In the rare instance that a patient is unable to wear their lens prescription, they will return (asap) for a prescription check evaluation, which is considered a Neurovisual Progress re-evaluation. This wording is very important in terms of insurance/billing.

These visits are usually “no charge” visits, however, all billing codes musts still be entered as usual. The opticians will adjust off any charges at the time of lens ordering.

Scribing a neurovisual progress re-evaluation (Rx Check) is similar to a contact lens exam, in that many of the tabs will have limited info entered. You would follow similar guidelines, and enter testing values when performed, and indicating in the Notes sections why specific tests are not performed.

You will not need to write letters for Progress re-evaluations even if the patient would usually have letters requested. This is the only situation in which you wouldn’t write a requested letter.

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** Of course, if a patient specifically requests a letter from this visit, you must generate one with the updated information.

Writing Letters

Letters, regarding the findings from the days visit, are written to physicians/case managers/lawyers and anyone else determined by the Patient. During their screening, the patient will be asked to fill out a Doctor Report Request (DRR), indicating who they would like a letter sent to.

Prior to handing off the patient’s chart to the examining doctor, you must retrieve the DDR in order to prepare the necessary letters.

You will find the Doctors listed on the Referral Sources section on the Patient Information page.

If the doctors aren’t listed

- You must add the doctor to the referral section by clicking: ADD and typing the doctor’s last name into SOURCE, and press F7.

If you see “Unable to locate any matches with this search Criteria”- The doctor is not in our data base, and must be added.- First find any missing information online

o Best method: Google the doctors name followed by “NPI”. Example: Dr. John Doe NPI

- Be smart about your search, and make sure to gather the following info:o Doctor (or other type of referral) full nameo Correct address, including suite numberso Phone and fax #s – fax numbers are absolutely necessaryo Physician NPI and licience numberso Type of degree: MD, DO, OD, NP, DC, etc.

- Once you have all the information you must go to the data base. o Compulink screen Utility Look Up Tables General Referral Sourceso To add the doctor, find their placement alphabetically, and click INSERT. The

doctor will be added above the highlighted line. o Fill out the form and click SAVE

Adding the doctor to the Referral sources section- Follow the steps listed above.- Must fill out the following boxes in this section:

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o Degreeo Specialty – free typeo Letter – type of letter depending on visito Reason – Doctor Referral for service (if referring person); Doctor report request

CC (everyone else)o Authorization: enter fax numbero Benefit: person characterization, either – Referral, CC, PCP , or Patient

- Once all filled in, SAVE (green check mark). - You can edit any information by clicking EDIT.

Returning Patinet

- The patient will only be given a DRR during initial/annual visits. During a follow up visit, you must always ask them if they would continue to have letters sent to the listed doctors

- If they would like to continue sending letters, Edit the date of the letter to match the date of the visit, and alter the Letter type.

No letter requested

- Follow the steps as if you were to add a doctor to the Referral Sources section, and type No Letters in the source section.

Once the exam is finished, and all necessary information has been entered, you are ready to write the letter. If there is a referring physician, address the letter to this physician. If not, choose the most logical choice: Ophthalmologist> PCP> chiropractor>Case Manager>Lawyer,

Generating a Letter

- Open doctor report list Print Letter choose down drop choose appropriate letter type

Every doctor likes specific information included in their letters, however, in general, the basic letter construction is the same. The following pages include real patient letter examples for the various doctors.

- Aim to include as much information as possible without adding numerical prescription findings.

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- AUTO patients specifically require very in-depth letters including severity of incoming symptoms, symptom improvement, and further plan of action. ** when in doubt, ASK THE DOCTOR!!

Saving a Letter

Save Netdrive Eye Care Compulink letters created and saved for VSofM Save the letter under the following name format:

(Patient Last name) (Patient 1st name) (Date of exam) Dr (letter addressed to) (Initial of scribe)

Ex: Doe Jane 8-23-13 Dr Smith NS *DO NOT use punctuations (periods, commas…)

Exporting a letter (only works in OpenOffice) - after you have already saved the letter

File Export as PDF OK OK Save *It should be saved on the desktop.

Printing/signing/faxing Letter

Once you have generated your letter, saved it in the Documents section of the EMR, and created fax cover sheets, you must have the doctor review and sign the letter. After the doctors signature, you may fax the letter.

Once letters has been faxed

Enter the date letter was faxed/mailed/given to necessary party in the Date letter sent section of EACH doctors listing. Also, sign your initials along with the date on the appropriate line on the exam form.

Written Paper Work

Sometimes, patients will have issues with the computer, or refuse to use a computer to complete their Web registration. In these instances they will be given the old paperwork to fill out their medical history. This paper work must be entered by the scribes manually, upon arrival of the patient’s chart. The written paper work can then be shredded, since it will have already been added to the EMR.

Staying organized

A scribe has a large list of things to do, but there is a short list I keep track of in an effort to keep my work organized, on track, and at the same time to help me maintain my sanity. I’ve developed a Patient check list that helps me keep track of my patient arrival times, insurance info, letter requests and exam

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form status. I write out this chart every morning and take it with me all over the office as I progress through my day. Here, I’ve generated a short version of the list to give you an idea of how you should be organizing your scribing thoughts. Hope it helps!

Insurance/Exam time

Exam Type

Patient Charges Exam Form

CCD Letters Fax File Sign Off NS

BCBS 7:40 AM

Initial Jane Doe √ √ √ (2)√ √ √

Medicare 9:00 AM

Annual John Smith √ √ (1)√ √

Auto 9:50 AM

F/U Billy Bob X x √

Self 11: 00 AM

CL F/U Dave Johnson (4)

Mock: Dr. ___________ Patient List √ = Done x = N/A

By using a chart like the one above, you can make sure you put through the charges, signed your initials on the exam form, Pulled up the CCD document, wrote the letters, faxed the letters, received the file (and waiting for Dr. Debby to sign off), and sign in/off under your initials.

Should you find another method that you find helpful, feel free to use it. But I highly recommend using some kind of checking system to ensure you get all your work done in a timely manner.

Green Sheet

Green sheets are given to the scribes by Angie; they represent errors in the medical record that are preventing billing from going through. The scribes must correct these errors in a timely manner, and return the sheet to Angie once they have been completed.

Because scribes often move from one doctor to another, not all the errors on a single green sheet may be yours. You are responsible for correcting the errors made in a record you scribed. Once you have corrected your mistakes, pass on the green sheet to the next scribe who may need it. Again, once completed, return the sheet to Angie.

Following, you will find the Supplemental Materials, beginning with examples of actual letters

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from the different doctors.

Friday, August 23, 2013

Patricia Toth

2475 Edgemont Street

Trenton, MI 48183

Dear Ms. Toth,

Hunter Wallace came for a progress evaluation on 8/23/2013 after having received his new glasses one month ago. His Vertical Heterophoria Symptom Questionnaire score is now 15. He describes his condition as being 75% improved. You mentioned that he is still tilting his head to the left shoulder, however the severity of the the tilt has reduced with this new prescription.

My evaluation today indicates that he is doing well with his current prescription; both his refractive and prismatic corrections are stable and require no change at this time.

Hunter will be seen for an annual visit in one years time, or sooner if necessary. I look forward to seeing you both then.

Sincerely yours,

Dr. Debby Feinberg

Dr. Debby

Follow Up

Pt doing well

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Friday, August 23, 2013

Sophia Grias, MD

29275 Northwestern Hwy Ste 100

Southfield Mi 48034Fax: (248) 869-3968

Dear Dr. Grias,

I had the pleasure of seeing Barbara Eberhart for a progress evaluation on 8/23/2013 after having received her new glasses two months ago. Her Vertical Heterophoria Symptom Questionnaire score is now 50. She describes her condition as being 10% improved. She has noticed with her current glasses that her head tilt and the need to watch the ground while walking has been reduced. Despite these improvements she is still experiencing right eye pain and headaches.

My evaluation today indicates that symptoms were reduced with a modification to the prismatic correction in her lens prescription. Upon increasing her vertical prism by one increment, she experienced overall enhanced visual clarity and comfort, along with a decrease in her incoming symptoms. In an effort to reduce additional visual strain, she is being prescribed near distance glasses to be worn during close-up viewing. Barbara scored a 12/13 on our Superior Semicircular Canal Dehiscience (SSCD) Questionnaire. Due to the inability to reduce all of her symptoms with prism lenses, she is being referred to Dr. Katherine Heidenreich, at the University of Michigan, for an evaluation of possible SSCD.

Barbara will be seen for a progress evaluation following her SSCD evaluation. I will update you as to his progress after this visit.

Once again, it was a privilege providing care for your patient.

Sincerely yours,

Dr. Debby Feinberg

cc: Dr. Muzaffa Awan

Dr. Debby

Follow Up

Pt needed change

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Dr. Niloffer Nisar Mrs. Barbara EberhartWednesday, August 21, 2013

Heather Burgess-Peterson, OD

1871 Holton Ste A

Muskegon MI 49445Fax: (231)744-6782

Dear Dr. Burgess-Peterson,

Curt Walker has requested that this information be sent to you:

I had the pleasure of seeing Curt Walker for a comprehensive vision evaluation on Walker for a comprehensive vision evaluation on 8/19/2013. As you remember, he is 66 years old and has been experiencing double vision several years. In addition, he has been experiencing difficulty with reading comprehension, words run together while reading, skipping lines while reading, closing or covering one eye while reading, dizziness/lightheadedness, tires easily with close-up tasks, sensitivity to bright lights, and feeling uncoordinated.

His Vertical Heterophoria Symptom Questionnaire score was 39. My evaluation indicates that there is an ocular cause for his symptoms. Today's diagnoses include:

Code: 378.43 Vertical Heterophoria Code: 780.4 Dizziness Code: 368.2 Double Vision Code: 368.13 Photophobia Code: 692.72 Photosensitive to Sun Code: 367.0 Hyperopia Code: 367.2 Astigmatism Code: 367.4 Presbyopia

He responded well to the trial-framing of the new lens prescription in the office, with a reduction in symptoms. Upon modifying his refractive and prismatic correction she experienced overall enhanced visual clarity and comfort at both far and near distances. I am recommending that he perform full range of motion exercises, where he will individually move his eyes to strengthen the eye muscles, in a z-pattern, then switch to h-pattern.

Curt will be seen for a follow-up visit after his evaluation with Dr. Stephen Sullivan. I will update you as to his progress after this visit.

Sincerely yours,

Dr. MaryJo

Initial

Complex

21

Dr. Mary Jo Ferencecc: Dr. Stephen SullivanFriday, August 2, 2013

Anthony Emmer, DO

26400 W 12 Mile Rd Ste 170

Southfield MI 48034Fax: (248)208-8788

Dear Dr. Emmer,

I had the pleasure of seeing Rose Jenkins for a progress evaluation on 7/30/2013 after having received her new glasses three weeks ago. Her Vertical Heterophoria Symptom Questionnaire score is now 17. She has noticed with her current glasses that she is unable to adjust to the progressive bifocal; causing her dizziness, and headaches. She is still experiencing lower back pain, however she is currently being treated by her orthopedic doctor.

My evaluation indicates that symptoms were reduced with a modification to the refractive and prismatic correction in her lens prescription. Upon trial-framing the modified correction, she experienced overall enhanced visual clarity and comfort at both far and near distances. She is being prescribed glasses for near point activities to eliminate symptoms that she was experiencing with the progressive lenses.

Rose will be seen for a follow-up visit one month after receiving her modified prescription. I will update you as to her progress after this visit.

Once again, it was a privilege providing care for your patient.

Sincerely yours,

Dr. MaryJo Ference

cc: Dr. Martin Kornblum Dr. Stephen Mendelson Dr. Heather Zacar Dr. Summer Fakhouri

Dr. MaryJo

Follow UP

Need change

22

Dearborn Center for Physical Therapy Mrs. Rose Jenkins

Tuesday, August 13, 2013

Randall Benson, MD

43000 W 9 Mi Rd Ste 116

Novi MI 48375Fax: (313)228-0931

Dear Dr. Benson,

Tana Beck has requested that this information be sent to you:

I had the pleasure of seeing Tana Beck for an annual neurovisual evaluation on 8/13/2013. As you remember, she is 37 years old and has been experiencing headaches, eye strain, and dizziness. In addition, she has been experiencing difficulty with reading comprehension, trouble concentrating, light sensitivity, tiring easily with close-up tasks, neck pain, pain with eye movement, feeling uncoordinated, and upper back or shoulder tension.

Her Vertical Heterophoria Symptom Questionnaire score was 35. My evaluation indicates that there is an ocular cause for her symptoms. Today's diagnoses include:

Code: 378.43 Vertical Heterophoria Code: 780.4 Dizziness Code: 787.02 Nausea Code: 784.0 Headache Code: 367.0 Hyperopia Code: 367.2 Astigmatism Code: 367.55 Accomodative Insufficiency

Tana responded well to the trial-framing of the new lens prescription in the office, with a reduction in some of her incoming symptoms. She experienced overall enhanced visual clarity and comfort at both far and near distances.

Tana will be seen for a follow-up visit after receiving her new lens prescription. I will update you as to her progress after this visit.

Sincerely yours,

Dr. Paul C. Feinberg

Dr. Paul

Annual

Need change

23

cc: Ms. Susan Johnson (case manager)DOCTORS NOTES

The doctor’s notes can make or break the task of relating the accident to your treatment. Below are some points to include in patient records.

New Patient:

1. You want to make sure the doctor’s notes start by stating the type and date of the accident.

2. Detail all symptoms the patient is experiencing after the accident. Talk about the degree of severity of symptoms.

3. Next, state which symptoms were not present prior to the accident or symptoms that were worsened after the accident. (ie: patient may have had occasional headaches prior to the accident that are worse or more often after the accident.)

4. State if the patient has a head injury and note the doctor and specific diagnosis the patient received if possible.

5. If your patient did not wear glasses prior to the accident, note it. It is harder to prove “relatedness” in patients who wore glasses prior to an accident.

6. State a summary of the plan and time frame to be treated.

Established Patient:

1. Start by again stating that the patient is being treated for an accident or injury and state the date of the accident.

2. State the symptoms that have improved since the patient’s last visit and use words like- “with the addition of prism”. Use the 0-10 number system to explain the amount of improvement.

3. State any symptoms that have been eliminated with the prescription of prism.

4. Next, list the symptoms the patient is still experiencing and again use the 0-10 numbering system to describe the severity.

5. State a limited summary of the plan and time frame to be treated again.

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Words to avoid in documentation:

1. Visual symptoms- this makes the insurance company think optical. (ie: near or far sighted.) Instead use the words medical symptoms, or just symptoms.

2. Patient has no symptoms. If the patient’s symptoms have been eliminated after the first visit and a new prescription is not necessary then state that. State what the previous symptoms were and note 100% improvement.

3. Check- up- this leads an insurance company to think the patient is having no problems/symptoms. Instead, use the word follow up or progress assessment, then go on to describe why the patient needed to be seen.

4. Re-check or prescription check. This again makes an insurance company think there are no symptoms relating to the accident. It also makes the insurance company think optical and not medical. Use the word follow up or progress re-evaluation.

5. Near sighted or far sighted. Be careful with these and if you must use them, state why the near or far vision was affected and how it relates to the accident.

6. Vision- while VH does affect how the patient sees as far as blurriness, double vision etc., it would be better to use the actual words blurriness or double vision.

7. Avoid statements like: patient is doing well with his vision. Instead talk about specific medical symptoms and improvements relating to accident.

8. Avoid saying the statement, the patient is here for a general exam with no specific visual problems. VH exams are never a “general exam” this implies optical exam.

9. Avoid a statement like this: it has been 3 years since his last eye exam. He is here for a check- up. Even if the patient had a lapse in annual visits, relatedness to the accident must still be noted.

10. Patient is here today to assess visual symptoms relating to his accident on ____________. Instead, just state the patient is here to have an evaluation to assess symptoms relating to his accident on __________.

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Medical Diagnosis codes used to document Neurovisual Exam

Abnormality/Staggering Gait- 781.2

Accomodative Insufficiency- 367.55

Anisometropia- 367.31

Astigmatism- 367.2

Anxiety- 300.02

Blurred Vision- 368.8

Dizziness- 780.4

Double Vision- 368.2

Esophoria- 378.41

Esotropia-378.0

Exophoria- 378.42

Exotropia- 378.1

Eye Pain- 379.91Eye Strain- 368.13

Headache- 784.0

Heterotropia-378.30

Hyperopia- 367.0

Hypertropia-378.31

Hypotropia-378.32

Nausea- 787.02

Neck Pain- 723.1

Photophobia- 368.13

Photosensitive to Sun- 692.72

Photosensitive other than to Sun- 692.82

Superior Oblique Palsy- 378.53

Superior Semicircular Canal Dehiscence Syndrome (SSCD) - 386.8

Vertical Heterophoria- 378.43

NEW PATIENT EXAM

99201- 10 MIN.99202- 20 MIN.99203- 30 MIN.99204- 45 MIN.99205- 60 MIN.

ESTABLISHED PATIENT EXAM

99211- 5 MIN.99212- 10 MIN.99213- 15 MIN.99214- 25 MIN99215- 40 MIN

EXTENDED FACE TIME

99354- New Patient (99205) 90 Min. With Patient Established (99215) 70 Min. With Patient

OPTOMETRIC SERVICES

92002- New Intermediate92004- New Comprehensive 1 Or More Visits92012- Established Intermediate92014- Established 1 Or More Visits

Extended Times & Prolonged Visits

99205

60 min. or more

90 or more add 99354

If you have 75-89 min- downcode to 99204 and add 99354

99204

45 min or more

75 min or more add 99354

99215

40 min or more

70 min or more add 99354

If you have 55-69 min. downcode to 99214 and add 99354

99214

25 min or more

55 min or more add 99354

Also, please use MEDICAL diagnosis codes. All medical should be listed first for all patients regardless of insurance as most of our patients are neurovisual exams. It is ok to list optical codes second.

New Exam

Time (mins) for Exam Codes:

> 90: 99205 + 99354 (60 min+30 min)

75-89: 99204 + 99354 (40 min+30 min)

60-74: 99205 (60 min.)

45-59: 99204 (45 min.)

Progress Assessment Established

Time (mins) for Exam Codes:

> 70: 99215 + 99354 (40 min+30 min)

55-69: 99214 + 99354 (25 min+30 min)

40-54: 99215 (40 min.)

25-39: 99214 (25 min.)

Scribe REMINDERS:

1. WHEN NUMBERING DX CODES IN THE PLAN TAB, PLEASE LIST VH OR OBLIQUE PALSY AS # 1. FOR NUMBERS 2-4 LIST MEDICAL DX CODES (HA, DIZZINESS ECT.) THE ONLY EXCEPTION MAY BE IF YOU ARE DOING A STRAIGHT OPTEMETRIC EXAM.

2. PLEASE REMEMBER TIMES FOR USING EXTENDED FACE TIME. ALSO, CHARGE EXTENDED TIME FOR ALL PATIENTS EXCEPT CASH AND MEDICARE PATIENTS, PER DR. MARK. 99205 = 90 MIN.

99215 = 70 MIN.

3. ALWAYS APPLY CHARGES TO A PATIENTS LEDGER BEFORE THE PATIENT GETS TO THE FRONT DESK. IT ELIMINATES SO MANY ERRORS AND IS MUCH MORE ACCURATE.

4. PAY EXTRA ATTENTION TO MAKE SURE TRIAL FRAMING IS CODED IN THE DR. BAG. IT IS THE HARDEST CODE FOR ME TO TRACK AND MAKE SURE IT IS BILLED. IF EITHER YOU OR I MISS IT, IT IS MONEY NOT COLLECTED ($100.00).

5. MAKE SURE TO DOCUMENT NOTES FOR ALL AUTO OR WORK COMP PATIENTS IN THE DR. BAG. MAKE SURE TO RELATE CARE TO THE ACCIDENT. INCLUDE SYMPTOMS AFTER ACCIDENT AND AVOID TYPING THINGS LIKE “GENERAL EXAM ONLY, NO SYMPTOMS, PATIENT ONLY HERE FOR A CHECK UP” THESE MAKE IT IMPOSSIBLE TO GET PAID FROM AUTO COMPANIES.