• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• Time spent outdoors, on near work and screen viewing
• Names of, contact information for, patient’s other health care providers

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Binocularity – ocular alignment (cover test, Hirschberg, Krimsky, Bruckner, Stereopsis, near point of convergence) Any of test is sufficient
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Tonometry (Tactile) – If child is cooperative
• Screening visual fields/confrontations at doctor’s discretion

*Note: Fundus photos and optomap^® retinal exams are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

• Fixation preference tests
• Bruckner’s test
• Preferential looking visual acuity test
• Fix and follow and Visual evoked potential

• Cycloplegic retinoscopy
• Static retinoscopy

• Identification and description of the chief complaint
• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history and review of systems
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• Time spent outdoors, on sports activities, on near work and screen viewing
• Names of, and contact information for, the patient’s other health care providers

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Binocularity – ocular alignment at distance and near (cover test, Hirschberg, Krimsky, Stereopsis,near point of convergence, Positive and Negative Fusional Vergence, Accomodative convergence) Any one test is sufficient
• Screening visual fields/confrontations at doctor’s discretion
• Color Vision Testing – Once in lifetime
• Tonometry – if child is cooperative

*Note: Fundus photos and optomap^® are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

Suggested measure of quantitative acuity, not limited to the following (recorded monocularly):

• Broken wheel acuity cards
• Lighthouse cards with matching blocks
• HOTV test
• Tumbling E chart
• Snellen acuity chart
• Lea symbols and Sloan letters

At least one, with corrected visual acuity as stated at left:

• Static retinoscopy
• Cycloplegic retinoscopy

Accomodative Function is a guideline based on the doctor’s professional judgment and not an exam requirement. Any near point accommodation testing is performed when clinically indicated.

• Identification and description of the chief complaint
• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• School performance history
• Time spent outdoors, on sports activities, on near work and screen viewing
• Names of, and contact information for, the patient’s other health care providers

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Binocularity – ocular alignment at distance and near (cover test, Hirschberg, Krimsky, Stereopsis,near point of convergence, Positive and Negative Fusional Vergence, Accomodative convergence) Any one test is sufficient
• Screening visual fields/confrontations at doctor’s discretion
• Color Vision Testing – Once in lifetime
• Tonometry Guideline: Attempt either applanation or noncontact at the earliest age that a child is cooperative. Tactile estimations acceptable if documentation supports the reason why numerical tonometry wasn’t performed.

*Note: Fundus photos and optomap^® retinal exams are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

Suggested measure of acuity assessment, any one test is sufficient. (Must be recorded monocularly):

• Bruckner’s test
•  Snellen acuity chart
• ETDRS Visual Acuity

• Static retinoscopy or Auto refractor results- acceptable in non-verbal patients
• Determination of refractive state with best corrected visual acuities (recorded monocularly). Testing may be delegated to qualified staff under the supervision of a licensed VSP Network Doctor (as permitted by state regulation) and may be done with or without DPA's (diagnostic pharmaceutical agents)
• Cycloplegic retinoscopy

• Accommodative Function is a guideline based on the doctor's professional judgment and not an exam requirement. Any near point accommodation testing is performed when clinically indicated.