Billing and Coding the Medical Eye Examination (45205-PM )


Site Administrator & Tech Lead
Staff member
Feb 24, 2001
University of Michigan Medical School
Lake Oswego
Lecturer: @Laurence Craig Thomas

You will learn how to properly report a medical eye examination based on Current Procedural Terminology (CPT) definitions. Topics include information on how to determine medical necessity and how to improve your medical decision making.

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to watch the recorded lecture & get CE credit through August 17, 2015.

Discuss the lecture and ask questions in the thread below.
Maybe I missed this in the lecture but for the GMO component of a comprehensive exam, is the doctor required to observe and document, or can this be done by a tech?
OK, so 45 views and no answers, here's mine:

8 QUESTION: What is meant by “general medical observation”? ANSWER: General medical observations refer to comments in the chart describing the patient’s overall systemic health or general constitution. Commonly we see notes such as: “Patient states she is healthy”, “patient states DM is well controlled”, “patient complains of recent onset of cold symptoms”. Without detailed instructions regarding documentation of the general medical observation, we believe there is some latitude in interpreting this requirement.

Y N Body features and symmetry
Y N Appearance Y N Nutritional state
Y N Weight
Y N Skin color
Y N Frequency and volume of breaths
Y N Hair distribution
Y N Odors

OK so considering the GMO information above from 2 sources, the top one from Corcoran Conslting and the bottom one from Mark Wright, OD, it seems a tech can do it.
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we've asked LCT to comment, I suspect he's busy with patients today :)

Dr. Vaxmonsky,

Sorry for the delayed response. If I see you at Vision Expo in Las Vegas this fall, allow me to purchase you a beverage and apologize in person.

Because we are highly-paid professionals, most of the time we can do what we want. Because CPT has no documentation guidelines on this service component, you can have your optometric technician observe the patient and document the findings or you can do it yourself. This freedom to do what you want is one of the hundreds of reasons I love being an optometrist.

I believe I can do a better job of performing a general medical observation than my technician. In addition, my understanding of how my observations will affect my medical decision-making is something none of my technicians can match.

For example, let's say my next patient is a 68-year-old black female coming back to the office for a six-month glaucoma evaluation. My technician has performed preliminary testing and the patient is sitting in the exam chair waiting for me to walk into the room. I walk in, smile, extend my hand for a shake, and say "Good morning Ms. Jones". She smiles, shakes my hand, as says "good morning" back to me.

Only thing is, when I walked in the room, I caught a little bit of an odor. You know, the "I didn't take a shower last night or this morning" type of odor and maybe not the day before either. It's not an overpowering odor, but it gets stronger as you get closer to her.

It is abnormal for human beings in American society to have significant body odor.


Then, without missing a beat, I noticed her hair was pretty unruly. It wasn't just ridiculous, but it had been many moons since this lady had had her black hair worked on. Let's just say - it wasn't pretty.

When she smiled, she had a few teeth missing. Not too many, but more than two. In my experience, when I see women with bad teeth, they've usually had a hard life.

As I began my portion of the examination, I turned to the computer and typed in the following, "An obese female in no apparent distress with poor attention to grooming".

I don't know if my technicians would have written that and I don't know if I feel like teaching them how to do it. They already do almost everything else. I might as well keep performing refractions and looking at people. Got to carry my weight around the office.

As I continued my examination, I determined that the patient's glaucoma was uncontrolled and she needed more aggressive treatment to preserve her vision. She was already on one drop plus her other systemic medications. Now, I had decisions to make.
  • Am I going to recommend further testing?
  • Am I going to change, increase, decrease, or discontinue medication?
  • Am I going to recommend surgery?
Well, ordinarily with a diagnosis of uncontrolled glaucoma, I would try to get the glaucoma under good control by adding a second drop. This is my first treatment option over 90% of the time. Why not? It works and it's pretty easy to do.

However, with this patient, I really wasn't sure that it would work because I didn't know if it would be easy. Remember, I'm sitting across from a 68-year-old snaggle-toothed lady who smells and is having a real bad hair day. If she can't bath herself, brush her teeth and comb her hair - is she really going to be able to keep up with a two-drop glaucoma regimen?

Probably not.

So in this case with this patient, my observations during the general medical observation service component of the eye examination absolutely affected my medical decision-making and led me to recommend laser surgery as the next treatment option for this lady instead of a second eye drop. It can make a difference who does the observing and who does the documenting. Just sayin...

Last, thanks for the extra work by looking up the references from Dr. Wright and Corcoran Consulting. All they did was confirm what I said - their are no guidelines. You can do what you want - but you better do something!

Craig Thomas
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Thanks and certainly no problem with the delay. Thanks for the example beyond a simple yes or no and while it makes total sense, and I will make me certain to do it(Doctor driven GMO), I hadn't thought it to be a common or significant factor in affecting my MDM. Thinking about that in the future, I can see moving to SLT recommendation as first line therapy more often with "certain" patients. Now that I have this in mind, I will try to pay attention to how often it affects what I do for/with patients.

Won't likely be at VE in Las Vegas, but possibly AllDocs Cancun. All-inclusive, so I'm buyin' if you're there.