Blogs or Books? Guesses or Guidelines? It’s time to get serious about good medical records.

By: Charles B. Brownlow, OD  (drbrownlow@pmi-eyes.com)

Several years ago, I found myself jumping from one eye care chat room to another, trying in vain to correct bad information about patient care and record keeping that kept popping up there.  It seemed that my colleagues in eye care would rather ‘take a poll’ of other ODs and staff (who didn’t know the answer either) rather than go to the only true authorities.  After getting totally frustrated in that ‘Whack a Mole’ environment, I respectfully and quietly withdrew from the milieu, and I haven’t missed it one bit.

Over a decade ago, during the ramp up to HIPAA, the rules changed essentially clarifying that Current Procedural Terminology (©American Medical Association), ICD-9, and the Documentation Guidelines for the Evaluation and Management Services (99000 visit codes) were the sole acceptable references for codes and definitions for the vast majority of health care services.  That thought clarifies nearly everything in health care…All a health care provider needs to do to learn about the logic of health care delivery, good medical record keeping, and accurate choices of procedure, visit and diagnosis codes is purchase the current year’s CPT and a fresh ICD manual and download the 1997 Documentation Guidelines from CMS.gov.

Based on the questions that I get every day from ODs and staff from around the country, it’s pretty clear that a majority of those offices do not have those key references available in-house, or they are not current, or they just don’t refer to them when question arise.  That’s pretty sad, I think.  CPT is available through our AOA.org/marketplace at $100 a copy.  The Documentation Guidelines are a free download (.pdf or Word) at cms.gov.  ICD-9 and ICD-10 are available as complete manuals for around $100.  So, for between $200 and $250 per year, key staff and doctors could become ‘experts’ on the chat room scene real quickly.

I’ll provide a couple of examples to support my point.  One of the long-raging arguments among eye doctors; at least twenty years; has been whether the CPT definition of the comprehensive ophthalmological service (92004/92014) includes a dilated fundus examination as a requirement.  The definition has not changed since 1992 and it has never included that requirement!  The CPT definition clearly lists “…examination with cycloplegia or mydriasis” among the tests that the service “…often includes, as indicated”.  “Often includes” does not equate to “includes” or “is required.”

I think the confusion may come from the requirements for the ‘comprehensive physical examination’ for the evaluation and management services (99000 codes), but it was made very clear back when the 99000 codes were introduced nearly twenty years ago that the CPT definitions are unique and distinct for each set of visit codes and that there are no crosswalks or comparisons between the two.  In short, “external and ophthalmoscopic examinations” are required elements for 92004/92014…Dilation is not.

One of the national speakers in the medical record area continued to state that dilation was a requirement. Every year I would hear that, refer to my then current CPT book for confirmation that I was still right, and shoot off an email to suggest that the speaker ‘change his tune’.  Months later, I’d hear that the message had not changed.  Finally, early one year, with the ink barely dry on my current copy of CPT, I heard again that dilation was required.  Instead of emailing again, I picked up the phone and called. “Hey, how are you doing?  Keeping out of trouble?  Family doing fine”, etc.  After about 30 seconds of small talk I dropped my challenge.  “It’s right there in the definition”, the speaker replied. Then it hit me and I responded, “Which CPT book says that?”  “Why, the (Brand X) CPT, of course”, he parried.  FLASH!  The lights snapped on.  He wasn’t using the only official CPT book, the AMA CPT, he was using a cheap imitation, the book that continues to confuse the issues, the (Brand X) CPT!

As with so many things, we must accept no substitutes.  If I’m ever in court, I’ll want an attorney who knows the laws and, when pressed, is able to refer to the current, official statutes that pertain to the case.  I’m not going to be very comfortable if the attorney attempts to reassure me by saying that she got the information off a blog or chat room, or that he called a couple of friends or read it in a novel.  The same is true with medical records.  The care you provide had better be consistent with accepted modes of practice; the standards of care; and the medical records you keep must demonstrate clear connections between the needs of the patient and what was done, and your choices of procedure and visit codes must have been chosen by comparing the content of the chart and the definitions in AMA CPT and the current ICD listings.

Relying upon trusted resources and references can help us avoid hassles and sometimes disasters.  I know you’ve been putting this off for a long time.  Just do it today.  Get your 2015 copies of CPT and ICD-9 (and ICD-10).  Read the introductions at the front of the CPT book and the front of the 1997 Documentation Guidelines.  And then refer to those key references when questions pop up.  You’ll sleep better…You’ll find yourself chuckling quietly when you ‘listen’ in on a discussion in a chat room or read somebody’s blog…Then, without typing a response, you’ll go to the references, double check your understanding of the question, and live happily ever after.  You’re welcome.

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Optometrists should be aware of legal and ethical reporting requirements

Keith R. Kerns, Esq.–OOA Executive Director

Optometrists are well respected professionals and are trusted members of any community.  As such, state law and the AOA’s Standards of Professional Conduct (Standards) place obligations upon optometrists to report abuse and neglect at certain times.  It is important for optometrists to be familiar with the legal and ethical requirements surrounding this important subject.

Section C of the Standards, entitled “beneficence” or “do good,” calls on optometrists to “have the responsibility to identify signs of abuse and neglect in children…and to report suspected cases to the appropriate agencies, consistent with state law.”

Ohio law confers a special obligation upon certain trusted members of society to take action in suspected cases of child abuse.  Ohio Revised Code section 2151.421 requires health care professionals acting in their professional capacity to immediately report that a child has suffered or faces a threat of suffering abuse or neglect.  For purposes of the requirement, a child is defined as any minor under the age of 18 and a developmentally disabled, mentally retarded or physically impaired child under the age of 21.

The directive in Ohio law is clear, but what constitutes “abuse” and “neglect” may not always be as clear.  Again, state law tries to provide some guidance on this issue.  The law defines an abused child as one who has been the victim of sexual activity or exhibits evidence of any physical or mental injury inflicted not by accident.

A neglected child is defined as a child who is abandoned, lacks adequate parental care or suffers physical or mental injury due to a parent or guardian’s omission.  Additionally, a child whose parent(s) or guardian(s) refuse “to provide proper or necessary subsistence, education, medical or surgical care or treatment, or other care necessary for the child’s health, morals, or well-being,” also meets the definition of a neglected child.

This guidance is helpful but even within these definitions, there is quite a bit of discretion placed upon the practitioner to determine whether a child is suffering from abuse or neglect.  An optometrist must evaluate the situation thoroughly and make a determination as to whether a reasonable person in his or her position believes that the situation constitutes abuse or neglect.  If it does, then the decision is clear.  An optometrist must report the issue to the proper authorities, in this case a local child services agency or law enforcement officer in the county in which the child resides.

An agency that receives the report may ask the optometrist to follow up with additional information in writing.  This written report should include the name and address of the child and parent(s)/guardian(s), the child’s age and nature of the injuries, abuse or neglect that was suffered, and any other information that may be helpful in establishing the cause of the injury, abuse or neglect.

In almost every instance, a report is considered confidential and the information contained within it and the name of the person who reported it is not to be released.  Additionally, the information in the report and name of the person filing the report cannot be used as evidence in any civil action brought against the person making the report.  Ohio law recognizes that these good faith reports are essential in order to protect the well-being of at-risk children and confers these necessary protections on those who report suspected abuse.

For more information on this important issue, please contact the OOA at (800) 874-9111.

*This information is intended to provide general guidance and should not be considered legal advice.  Optometrists and staff should rely on the advice of their own legal counsel on specific issues.

Recommending ocular supplements blindly: more harm than good?

By Dr. Renee Rambeau,

The media is full of mixed messages, bombarding consumers (our patients) with unbelievable amounts of advertising including hundreds of messages about health, wellness and nutritional supplements.

As doctors, our patients look to us for sound advice regarding the addition of vitamins as prevention and treatment for ocular conditions including blinding eye disease like age-related macular degeneration. With the recent publication of the AREDS 2 study, the picture seems to be even more muddled than before. This post will help to clarify this controversial topic.

Research

– AREDS (NEI sponsored study) and other research published in the last several years have consistently produced statistically significant results that highlight the importance of recommending lutein & zeaxanthin to slow the progress of AMD. Few ODs would argue these results.  These studies show a minimum of 10mg/day of lutein and 2mg/day of zeaxanthin. So where is the controversy?

Supplements: empty promises?

Supplements are a dime a dozen but which products really contain the quality ingredients the labels promote?

-Just recently, major headlines were made by the New York Attorney General Eric Schneiderman requesting that hundreds of supplements be pulled from the shelves after a study by Clarkson University demonstrated that 4 of 5 supplements contained none of the ingredients listed on the label.

– Another study published online in the American Academy of Ophthalmology Journal in the fall of 2014 concludes that the “majority of top selling ocular nutritional supplements did not contain identical ingredient dosages of the AREDS or AREDS 2 formulation”.

Prescribing supplements

With all this conflicting information, what do we prescribe for our patients? And yes, I did say prescribe…after all we don’t hesitate to choose the proper antibiotic or intraocular pressure lowering drop if indicated by exam findings. Why should we hesitate to prescribe a product that research has proven to help slow the progression of a blinding eye condition?

The first recommendation is always whole foods; incorporating a variety of fruits and vegetables into a daily diet and aiming for 7-10 servings of these nutrient rich foods every day and a goal of 10mg of lutein and 2mg of zeaxanthin.  Here are just a few examples of dietary sources of these powerful antioxidants.

Good Food Sources of Lutein and Zeaxanthin (mg/serving)

Food/Serving
(1 cup)
Lutein and
Zeaxanthin
Lutein Zeaxanthin
Kale 20.5 – 26.5* 1.1 – 2.2*
Collard greens 15.3 5.1
Spinach 3.6 – 12.6* 1.7 – 13.3* 0.5 – 5.9*
Turnip greens 12.1 0.4
Broccoli 2.1 – 3.5* 1.4 – 1.6*
Corn, yellow 1.4 – 3.0 0.6 0.9
Peas, green 2.3 2.2
Orange pepper 1.7
Persimmons 1.4 0.8
Tangerine 0.5 0.2

*depending on variety and preparation

Source: USDA-NCC Carotenoid Database, 1998                                                                                                                        USDA Food Nutrient Database for Standard Release 13                                                                                          Hart and Scott, 199 HHN-1550B/0502

What happens if the patient in my chair is unwilling to try whole foods?  If the patient in my chair is hesitant to change his/her diet (or limited by other health conditions), my second recommendation is Juice Plus. Juice Plus is whole food nutrition in a capsule. The product is produced by dehydrating whole foods (fruits, berries and vegetables), utilizes a nutrition label instead of a supplement label and is backed by a significant amount of clinical research.

 

Ocular Nutrition

By Dr. Katherine Bickle

Shortly before writing this, I had a conversation with a new patient regarding nutritional supplements. Her history was positive for pigmentary changes in the maculae, and she reported the use of a nutritional supplement. Since the patient is a current smoker, I discussed with her the importance of taking a supplement without beta-carotene.  She recalled this conversation with previous optometrists, and we discussed the presence of beta-carotene in several formulations. From this conversation, both the patient and I developed a better understanding of the various commercially available formulations. The importance of these discussions with our patients cannot be overlooked. Not only can your patients learn from your expertise, but you can also expand your knowledge.

You may know the formulation of certain brands you commonly recommend to your patients. For those you aren’t familiar with, how do you easily distinguish among the marketed brands?  What are we doing on a daily basis to provide our patients with optimal care while striving to improve each patient’s quality of life?

Discussion with your patient

Recommending the proper nutritional supplement for your patient with AMD, MGD, and/or dry eye disease requires a thorough medical history, examination, and discussion with your patient.

Questions to consider asking your patient include:

  • Do you have a personal history of AMD, MGD, or dry eye disease?
  • What has been the impact of previous and current condition(s) and treatment(s) on your quality of life?
  • Which supplements, if any, have you used previously?
  • Which supplements have resulted in bothersome side effects for you?
  • How often do you take the recommended nutritional supplements (if previously prescribed)?
  • What are your short and long-term goals related to vision, comfort, and health?

AMD, MGD, and Dry Eye

Practitioners have differing philosophies on prescribing nutritional supplements for conditions. The AREDS (Age-Related Eye Disease Study) and AREDS2 have provided us with valuable information that we can incorporate into our daily patient care. More information regarding the AREDS2 can be found at http://www.areds2.org. While the AREDS2 reported that the addition of omega-3 fatty acids was not beneficial in the treatment of AMD, the literature suggests that omega-3 fatty acids may be beneficial for those with MGD and/or dry eye disease.  The International Workshop on MGD lists increasing dietary omega-3 fatty acid intake in the treatment algorithm for MGD. If you’re considering recommending omega-3’s to a patient, it is important to ask your patient about the use of blood thinners. Omega-3’s have been shown to cause additional anticoagulation effects when used with blood thinners. It is important to recommend an appropriate dose of omega-3’s that do not significantly raise the patients’ international normalized ratio (INR).

There are several commercially available supplements available for our patients. Do you have one supplement you recommend or do you give the patient options, and let the patient choose?  Do you make your recommendations from reading the literature, speaking with colleagues, or from your personal experience? While supplements may be less expensive or have less side effects than some prescription medications, your patients may not perceive the value in taking these supplements unless you discuss the potential benefits with the patient.  I encourage you to follow-up with your patients regularly regardless of your recommended treatment. When treating a patient for MGD and/or dry eye, discuss how their symptoms have changed since beginning the treatment. These are questions you can ask your patients directly or have your staff provide questionnaires for the patient to complete.

Patients appreciate the personalized care you provide them, the time you spend addressing their needs, and the appropriate treatment options you prescribe. Incorporating ocular nutritional supplements into your treatment plan can improve your patients’ ocular health and quality of life.

Your Opportunity to Provide for Patients with Visual Disabilities

By: Dr. Gregory Hopkins

I think it’s fair to say that we, as optometrists, are all in the business of helping people. Much professional satisfaction can be gained from correcting patients back to 20/20 with the right glasses, contacts or successful surgical co-management! For your patients for whom nothing more can be done refractively (or otherwise), it’s probably the case that they are concerned about continuing to lead quality lives. Maybe they’ve expressed worry about renewing their driving privileges, keeping their jobs or purchasing the right magnifier.

Opportunities for Ohioans with Disabilities (OOD) is the agency that directs our state’s Bureau of Services for the Visually Impaired (BSVI). BSVI is a vital referral resource to have at your fingertips, whether you offer low vision services in your practice or not. Upon your recommendation, BSVI will interview your patient and can potentially “open a case” for them. Your patients will receive the support necessary to use their remaining vision to succeed at work and at home. None of us like sending patients out the door without hope or solutions to their vision problems. Earn their gratitude and continue to gain professional satisfaction from these patient encounters by taking the time to download and use the referral resources below!

What BSVI is all about

BSVI Referral Form for Low Vision Services

PDF BSVI Eye Report (Fillable)

Visit http://www.ood.ohio.gov/ to find out more!

 

Pediatric Eye Care: Our Duty to Educate and Promote Available Programs

By: Kari R. Cardiff, O.D.

We all can agree that proper eye care is essential for infants and children. Why then are we still encountering a twelve-year-old child with refractive amblyopia who has never been examined and has never worn glasses or patched? I believe it is partly because the child’s family was never told to get their child’s eyes examined. Since the child has clear vision in one eye, the child never complained. Perhaps the child had a school screening but the good eye was tested first and the child memorized the letters? I feel that conversations about InfantSEE, RealEyes, and pediatric eye care in general should be a standard in our everyday lives as eye doctors. Whether the child is seven months old or twelve years old, normal visual development and clarity is essential for taking in all the world has to offer.

During the first several months of a typical child’s life, the brain is intensely attending to all new sights, sounds, tastes, and touches. When the brain is so accepting of new information and change, it can be easily transformed for the better or for the worse. For instance, any disruption in binocular vision in a young child can result in amblyopia. We are aware of the fact that a non-premature, developmentally classic baby should have their first eye exam between six months and twelve months old. When is the last time you told someone this or about the InfantSEE program and the importance of an eye exam before age 1? I take advantage of every opportunity to inform people about these things. Here are some examples of situations where I have had the opportunity to educate on InfantSEE: when examining an expecting parent (female or male); when examining older siblings of infants; and in conversations with friends and family. This is my usual statement: “Did you know I offer free eye examinations to babies 6-12 months old here? It is through a program called InfantSEE. We will assess the baby’s visual behavior, ocular health, glasses prescription, and eye alignment. This exam can be imperative for the baby’s vision development. A baby’s eye examination is quite different than an adult’s. Don’t worry, I won’t be asking them what is better, 1 or 2?” After the exam, I send a report to the patient’s family and pediatrician to keep everyone informed. Even if you do not participate in the InfantSEE program, I am sure the Ohio Optometric Association would be happy to connect you with someone who does.

As all of us were taught, 80% of learning occurs through vision. Typical school-aged children require clear and comfortable vision for effective learning. Most school nurse and pediatrician office screenings do a wonderful job of prioritizing patients and separating out the normal from abnormal; however, I feel that it is still important to remind parents, teachers, pediatricians, and school nurses that nothing replaces a complete and dilated eye examination with an eye doctor who is comfortable seeing children.

I am a RealEyes presenter and the programs and curriculum are always fantastic and age-appropriate. But I strongly believe the most important part comes at the end of presentation when I hand out the worksheets and state, “Please go home and show this to your family. Tell them that you want to go to the eye doctor for an examination. Tell them about what you learned today. Even though you may think you see well, an eye doctor can make sure your eyes are healthy and are functioning at the best of their ability.”  Even if only 25% of the children go home and follow through, that is still 25% more children getting eye examinations. For ‘Sammy Safe-eyes,’ the pre-K and Kindergarten curriculum, I inform kids that when they sign their name at the bottom of the first page this acts as a promise that they will go home and share what they have learned with their family. Also, with each visit to the school, I am able to interact with school nurses and teachers. I always heighten their awareness regarding the importance of eye care. Some teachers do not know about VSP school vouchers for students with suspected poor vision and limited resources for eye care. I always give out my business cards to teachers and school nurses.  I make it a point of letting them know that they should not hesitate to call me with questions or concerns about their students. Additionally, I also often ask friends and family who are teachers in Ohio if RealEyes is presented at their school. If it is not, I take whatever steps I can to further the prospects of these schools having the program.

We should all strive to take every opportunity to educate parents, teachers, nurses, pediatricians, and friends about the importance and significance of appropriate vision care for all of the infants and children we encounter. A definite here is that we all love eye care.  Who doesn’t love kids? No eye doctor can deny their love of talking about eye balls! I believe that more consistent discussions and proactive education in regards to InfantSEE, RealEyes, and general pediatric eye care can make a priceless difference in countless numbers of children’s lives.  Please do your part.