Guide to supplementary reason codes

This guidance, clarifying the use of these supplementary reason codes, was produced in consultation with the Scottish Government Health Directorates and Optometry Scotland.

If you carry out a supplementary eye examination on the same day as a primary eye examination, full details of the reasons why must be provided in the patient’s records. You must enter the relevant reason code on your claim.

For the purposes of NHS primary and supplementary eye examinations, a "sight test" means a refraction.

A supplementary eye examination can't be claimed on the same day as a primary eye examination for the same patient, if you're using any of the following reason codes:

• 2.1
• 2.7
• 4.1
• 4.6
• 4.7

Reason codes 2.5, 2.8, 4.5 and 4.8 should also only be claimed on the same day as a primary eye examination for the same patient, where the supplementary eye examination is an emergency.

Standard Supplementary Eye Examination

See the codes below and add them to your claim if necessary.

2.0 – Cycloplegic refraction following routine primary eye examination on a child

Use this code when a child requires a cycloplegic refraction following a routine primary eye examination.

2.1 – Paediatric review (without dilation/cycloplegia that does not follow a primary eye examination)

Use this code to review a child within 12 months of a primary eye examination, as judged clinically necessary, when dilation/cycloplegia is not required.

2.2 – Follow-up / repeat procedures (without dilation and not associated with glaucoma)

Use this code for additional or repeat procedures – not requiring dilation – that are required to refine a diagnosis or clinical outcome.

This will determine whether the patient needs referral or can be retained for ongoing care in the community.

This code can also be used for a refraction on a separate day, that could not be undertaken at the primary eye examination.

2.3 – Suspect glaucoma (without dilation)

Use this code specifically for suspect glaucoma review, in keeping with SIGN 144 guidance for diagnosis and referral for glaucoma. This includes ocular hypertension. Dilation should not occur.

2.4 – Patients aged under 60 requiring dilation following primary eye examination

Use this code following a primary eye examination, for a supplementary eye examination of a patient aged under 60 that needs dilation.

2.5 – Anterior eye condition (without dilation)

Use this code for a supplementary eye examination of a patient with a suspect or diagnosed anterior eye condition within the normal interval between primary eye examinations. Dilation should not occur.

2.7 – Post-operative cataract examination (without dilation)

Use this code for a post-operative cataract examination of a patient, which includes refraction, an ocular examination and – if required – a feedback report. Dilation should not occur.

2.8 – Unscheduled appointment (without dilation)

Use this code for a supplementary eye examination for a patient who presents with symptoms for an unscheduled visit within the normal interval between primary eye examinations. Dilation should not occur.

2.9 – Cataract referral advice and counselling

Use this code when providing advice and counselling to a patient following an eye examination that's resulted in the patient being considered for referral.

This may include providing prognosis or counselling and preparation for consent for cataract surgery, including risk factors.

3.0 – Additional appointment to complete primary eye examination for a patient with complex needs

Use this code when an additional appointment is required to complete a primary eye examination for a patient with complex needs. Usually, more time is needed to complete the examination in practice premises.

Only use this code when it hasn't been possible to finish a primary eye examination in the time scheduled and the patient needs a further appointment.

A patient with complex needs is a patient who has a physical or mental condition. As a result of that condition, the patient’s primary eye examination must be conducted significantly more slowly than that of a typical patient.

Avoid treating a patient as if they have complex needs solely due to their age.

Enhanced supplementary eye examination codes

Conduct an enhanced supplementary eye examination when you deem it clinically appropriate to support the care of the patient.

4.1 - Paediatric review (with dilation/cycloplegia that doesn't follow a primary eye examination)

Use this code when you review a child within 12 months of a primary eye examination, as judged clinically necessary, and dilation/cycloplegia is required.

4.2 - Follow-up / repeat procedures (with dilation and not associated with glaucoma)

Use this code for any additional or repeat procedures requiring dilation that are required to refine a diagnosis or clinical outcome. The result will determine whether the patient needs referral or can be retained for ongoing care in the community.

4.3 - Suspect glaucoma (with dilation)

Use this code specifically for a suspect glaucoma review, in keeping with SIGN 144 guidance for diagnosis and referral for glaucoma, and which requires dilation. This includes ocular hypertension.

4.5 - Anterior eye condition (with dilation)

Use this code for a supplementary eye examination of a patient with a suspect or diagnosed anterior eye condition within the normal interval between primary eye examinations. Dilation will occur.

4.6 - Cycloplegic refraction of a child referred from the hospital eye service

Use this code when facilitating the cycloplegic refraction of a child aged under 16 referred from the hospital eye service. The supplementary eye examination must include an internal and external examination of the eye.

4.7 - Post-operative cataract examination (with dilation)

Use this code for a post-operative cataract examination of a patient, which includes refraction, an ocular examination and (if required) a feedback report, and also requires dilation.

4.8 - Unscheduled appointment (with dilation)

Use this code for a supplementary eye examination for a patient who presents with symptoms for an unscheduled visit within the normal interval between primary eye examinations. Dilation will be required.

Further information and support

The codes were updated following the introduction of Primary Care Amendment letter, PCA(O)(2018)02 . They apply to all supplementary eye examinations carried out on or after 1 October 2018.

Please don't hesitate to contact the team if you have any questions or queries on the above.

Email: nss.psdophthalmic@nhs.scot

Telephone: 0131 275 6200