Test Survey

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Hello Doctor:

You are invited to participate in our survey regarding coding for optometric examinations. The survey asks questions about how you would code a patient exam. There will be a patient case with description about the examination. It will take approximately 5 minutes to read the case and complete the questionnaire.

Your participation in this study is completely voluntary. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. But it would really help us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Kate Vanderhoof by email at [email protected]

Thank you very much for your time and support. Please check the "I agree" box if you wish to participate and then complete the survey.

I Agree

Exam Information

A forty nine year old male patient presents to your office for his yearly diabetic eye exam. He has been examined by you one time previously two years prior. At that visit, there was no retinopathy found in either eye and only reading glasses were prescribed. All other ocular history is unremarkable.

Chief Complaint: Diabetic Exam

HPI: Patient is a type II diabetic with controlled blood sugar. He was diagnosed with diabetes 4 years ago. Reports good vision with no changes noticed.

Review of systems
Constitutional/general health: denies
Ear/nose/throat: denies
Cardiovascular: Hypertension
Pulmonary: Asthma
Endocrine: Type II Diabetes
Dermatological: denies
Gastrointestinal: denies
Genitourinary: denies
Musculoskeletal: denies
Neurologic: denies
Psychiatric: Depression
Immunologic: denies
Hematologic: denies
Eyes: Presbyopia

Personal/Family/Social History
Type II Diabetes Mellitus, previous alcoholic, denies smoking.Father has macular degeneration, brother has diabetes.

Exam Elements Performed (patient was dilated using 1% Tropicamide)
Visual Acuity (refraction was performed)
IOP
Mood/Affect
Adnexa/Lacrimal
EOM/Cover test
Lens
Cornea
Confrontation Fields
Optic Disk
Pupils/Irises
Conjunctiva
Anterior Chamber
Posterior Segment
Orientation

Additional Testing: Fundus Photos

Exam Results:
At this exam diabetic retinopathy was found in both eyes that was not there at the previous examination. Two microaneurysms were found in the right eye, and one was found in the left. Fundus photos were taken to document the changes found. Based on the exam findings, here are the appropriate diagnoses for the examination.

Diagnoses:
1. Diabetes Mellitus Type II controlled with retinopathy 250.50
2. Mild Nonproliferative Diabetic Retinopathy OU 362.04
3. Presbyopia 367.40
4. Myopia 367.1

Plan:
Patient to return in 6 months for dilated fundus exam to monitor retinopathy. Patient education on condition and importance of good blood sugar control. New glasses ordered with updated prescription.

Please check this box if you wish to participate in the survey, and then please answer the questions below

Based on the diagnoses given for the patient, what code would you use to bill this patient? If multiple codes are used, list all of them here. (you may use CPT codes or an S code, whichever you feel appropriate)

Please provide a brief explanation of how you came to your coding decision

What type of practice setting are you in?

Who does the coding for your examinations?

(if it is a staff member please state their title)