Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 402.000 - Vision Care Services
Section 402.417 - Recordkeeping Requirements

Universal Citation: 130 MA Code of Regs 130.402

Current through Register 1531, September 27, 2024

(A) A vision care provider must maintain a suitable medical record for each member for a period of as long as the minimum period required by 130 CMR 450.205(G). The record must fully disclose all pertinent information about the services furnished, including the date of service, the dates on which materials were ordered and dispensed, and a description of materials ordered and dispensed (including the frame style and the manufacturer's name). All findings resulting from vision care services, whether they are normal or abnormal, must be recorded. When extenuating circumstances prevent the use of one or more procedures normally performed in vision care services, the record must contain the reasons that the tests were not performed.

(B) For comprehensive vision care examinations and diagnoses performed in the office, a nursing facility, a hospital, or the member's home, the record must contain the following information or test results:

(1) case history;

(2) visual acuity testing;

(3) ophthalmoscopy and external eye health examination;

(4) ocular mobility testing, heterophoria testing, and fusion testing;

(5) pupillary reflex testing;

(6) refraction (objective, subjective refraction, and keratometry);

(7) confrontation fields or other screening tests;

(8) tonometry;

(9) case analysis and disposition; and

(10) biomicroscopy.

(C) All consultation services must be fully documented in the record. A record for a consultation must contain the following information:

(1) the member's complaints and symptoms;

(2) the condition of the eye; and

(3) if applicable, the name of the person to whom a referral was made.

(D) All screening services must be fully documented in the member's record. A record for a screening service must note the chief complaint and must contain all findings of two or more of the following tests:

(1) distance vision and near vision;

(2) cover test;

(3) visual skills;

(4) tonometry;

(5) biomicroscopy.

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