Authority to Order Imaging

THE AUTHORITY OF A NORTH CAROLINA LICENSED OPTOMETRIST TO ORDER IMAGING IN THE COURSE OF THEIR PROFESSIONAL PRACTICE.

The question is one of the authority of a duly licensed optometrist in North Carolina to order imaging studies in the course of their practice when their examination and/or findings indicate that the patient’s vision problems and/or complaints might be related to a condition or conditions whose diagnoses is dependent upon findings that can only be obtained and/or verified through imaging. Further, can a facility providing such imaging service(s) be denied payment by third party payers based solely on the fact that the procedure(s) was ordered by an optometrist?

HISTORY

In the past there have been isolated instances where a facility offering “imaging services” to the medical community denied patients access to their services when the practitioner ordering such services was an optometrist. As an increasing number of optometrists gained hospital privileges fewer and fewer complaints were received by the Board. Only recently did the Board receive information that a facility that had provided imaging on the order of an optometrist was denied payment for their services because the procedure was ordered by an optometrist.

BACKGROUND

The use of imaging studies in primary eye care is well documented. Such studies pertinent to an optometrist in the rendering of primary eye care services are many and vary in the rationale for the initial ordering of the images. Some of the more common imaging studies that the optometrist might have the occasion to order that are not usually available in the provider’s office include, but not necessarily limited to, the following: plain film x-rays, computed tomography (CTscan), magnetic resonance imaging (MRI) with and without enhancement techniques, MRA (magnetic resonance angiography), MRV (magnetic resonance venography), ultrasound, both A-scan and B-scan ocular ultrasonography, carotid ultrasonography (carotid doppler), temporal artery ultrasonography and echocardiography, to name but a few. Many imaging studies are performed with a variety of contrast materials typically administered by the attending radiologist, the interpreting radiologist, or a designee thereof.

CLINICAL PRACTICE

The ordering of the appropriate imaging study is typically driven by the clinical findings that the primary care optometrist encounters in the physical examination of the patient. During the course of the examination he or she may encounter several signs and/or symptoms, as well as suspect clinical findings, that suggest the presence of underlying disease that may not be readily assessed without imaging studies. It is the clinical decision of the practitioner in such situations to order the appropriate imaging study(s) to assist in the appropriate management or referral of the patient. While the clinical decision making process will vary depending on many factors, the findings of the physical examination as well as the multiple differential diagnoses that exist given certain presentations are paramount in arriving at the decision to order a particular image study(s)

While imaging technology(s) is constantly changing and improving and while imaging paradigms will likely change over time, the rationale for ordering such studies is more stagnant. There are many reasons why imaging studies may be requested, including the following (relevant examples are included as a guide and are not meant to be all inclusive):

• DIFFERENTIAL DIAGNOSIS. _ In the instance that a patient who presents with proptosis and EOM restriction, thyroid orbitopathy and orbital myositis. Here is an example where the differential diagnoses can only be differentiated by imaging (usually MRI) evaluating specifically the size of both the bellies and insertions of the extraocular muscles.

• DIAGNOSTIC CONFIRMATION. _ In the instance where a patient presents with classic findings of thyroid abnormalities including abberant laboratory studies and proptosis. The diagnosis of throid orbitopathy is highly suspected and is confirmed by imaging.

• OBJECTIVE MEASUREMENT. _ In the instance where a patient presents with a visual field defect suggestive of chiasmal etiology. Imaging is important in being able to objectively measure the size of a space occupying lesion since that may play a significant role in the appropriate management of that patient. Follow up of carotid artery disease is another example of the use of imaging to objectively measure change over time.

• EVALUATION FOR UNSUSPECTED ILLNESS. _ When used judiciously this is an appropriate rationale for ordering imaging studies, especially when the clinical presentation and findings do not point to a specific set of differential diagnoses as in the case of the patient who presents with visual field defects with a history of complicated migraine.

• MEDICO-LEGAL JUSTIFICATION FOR IMAGING. _ Instances may well arise where a patient’s complaints are out of proportion to the pertinent positive clinical findings thereby raising the specter of occult disease. This is especially true in cases where a review of systems unveils several seemingly disparate problems that may or may not be currently under control. Imaging should not be used to ‘cover bases’, but should be employed when there is a high level of suspicion for an underlying disease process.

SUMMARY

While imaging technologies and paradigms used today will be different in the years to come as newer technologies and improved imaging techniques become available, the need for optometrists as primary eye care practitioners to order imaging studies in specific instances, either as primary or adjunctive therapy in the work-up and continued management of selected patients, will remain so long as the public looks to members of their profession as the preferred providers of primary eye care.

STATEMENT OF POLICY

First and foremost it is the opinion of the Board that the process behind the ordering of a specific imaging procedure(s) is crucial in evaluating the appropriateness of the requested imaging study; therefore, clinical findings including a detailed history that support the need for ordering a particular image procedure should be well documented in the patient’s chart. Imaging should not be used in a blanket fashion to “fish for” positive clinical findings. The ordering of imaging should be quite specific to the needs of the patient and must be based upon findings that are communicated to the radiologist or other physician performing and/or interpreting the procedure to enable him/her to more accurately evaluate the patient.

In a proper case where the clinical and other findings including the patient’s history and complaint(s) are properly documented in the patient’s chart by the examining optometrist, it is the opinion of the Board that it is both appropriate and within the scope of practice of optometry in North Carolina for that optometrist to order a particular imaging procedure(s), and that the order for the procedure(s) should be honored by a facility in North Carolina offering such imaging procedure(s). When the results are reported by the radiologist or other physician performing and/or interpreting the imaging procedure to the optometrist ordering it the optometrist is to make the report a part of the patient’s permanent record. Should the findings indicate an underlying disease process requiring referral of the patient to another provider then the optometrist is to make known to that provider when communicating on the patient’s behalf the results of the imaging procedure in addition to their own clinical findings.

Finally, given the fact that it is the opinion of the Board that a North Carolina licensed optometrist’s scope of practice enables him or her to order imaging procedures in a proper case, it follows that a facility performing the procedure and/or those interpreting same should be entitled to reimbursement in the same manner and in the same amount had the procedure(s) been ordered by a physician, dentist or other licensed health care provider who may order imaging during the course of their professional practice.

Adopted 03/31/07