VSP "Routine/Wellness"
Exam Requirements
VSP has two levels of routine or wellness exam: comprehensive and intermediate. They also have special exam rules for diabetic patients.
It is essential to know these requirements; failure to document them per the provider reference manual is an audit trap. It does not matter that you DID them, it matters that you have DOCUMENTED that you did them. Recently, in 2026, during VSP's SIU audits, VSP has started rejecting examinations if they are missing -- a SINGLE -- required element. However, it is almost impossible to KNOW what is actually required. The following will provide some guidance. But one thing is clear: if your documentation is "sketchy" or incomplete, expect a bad result from an audit!
The five components of the standard/wellness exam, and what each encompasses, as described in the VSP manual are as follows:
1. CASE HISTORY
- Chief complaint/reason for the visit
- Medical history and review of systems
- Ocular history (including family)
- Medicine history (prescription and OTC)
- Allergies
- Social history including visual demands of work/school
2. ENTRANCE TESTS
- VA with and without current Rx
- EOM and vergences
- Screening fields
- Pupils
- Tonometry
3. REFRACTIVE STATUS
- Objective refraction
- Subjective refraction
- Lensometry (if applicable)
- Keratometry (when applicable)
4. OCULAR HEALTH
- Slit Lamp/Biomicroscopy (conjunctiva, cornea, lids/lashes, lens)
- Direct ophthalmoscopy or BIO (c/d, nerve, macula, vasculature)
- Dilated fundus exam (in the absence of medical contraindications)
5. ASSESSMENT AND PLAN
- Document the clinical findings
- Prescription of medications, glasses, or contact lenses
- Recommendation for treatment plan
- Follow-up schedule/plan
This is where the VSP manual starts to get messy and confusing. VSP's manual says that "all 12 elements of the exam" are required to qualify as a Comprehensive Exam. It does not, however, identify the "12 elements" or which elements are included in that 12, nor does it clarify how optional elements fit into the requirements. The manual also says that Intermediate exams must meet the same "Case History" and "Diagnosis and Treatment Plan" criteria as a comprehensive exam, except there is no section labeled "Diagnosis and Treatment Plan." Presumably they mean the Assessment and Plan, but that is not what it says.
Experience indicates the following are going to be required by VSP and if ANY ONE is missing VSP will deny the exam and/or may reduce it to an intermediate exam (if everything but tonometry is there it is usually reduced to intermediate; tonometry appears to be a litmus test for VSP to qualify as a comprehensive exam).
- Entrance acuities - it appears that either with or without Rx will be accepted, but there must be monocular entrance VA's recorded.
- EOM - some notation that muscles were checked such as "EOM full"
- Vergences - some notation of phorias or near point of convergence
- Pupils - PERRLA or something similar
- Fields (confrontation or other screening) - some field testing result such as "CF full"
- Tonometry (or a reason why it could not be performed)
- Slit Lamp/Bio (cornea, lens, adnexa, lids/lashes, conjunctiva)
- Ophthalmoscopy (c/d, nerve, fundus, macula, vasculature)
- Subjective Refraction with monocular best-corrected acuities
It is not clear what else is required in the exam to get to the 12 requirement elements. Objective refraction (auto-refraction or retinoscopy) has not usually been required. But perhaps it is if 12 elements are required. Same with keratometry.
NOTE: Retinal imaging and OCT does not count; it does NOT satisfy the requirement for ophthalmoscopy nor does it satisfy the requirement of a dilated fundus examination. If your only indication in the chart of a retinal exam is via imaging your exam will be rejected as lacking required documentation! That said, VSP cannot generally determine from your chart -how- you determined c/d, macula, vasculature, etc., but there must be notations of those, and there should be a notation of whether the patient was dilated or not, and if not, why not ("dilation declined by patient").
COMPREHENSIVE EXAMS
As noted above, VSP expects "all 12 elements" to be there for a comprehensive exam. VSP has been routinely asserting that exams are not adequately documented because requirement elements are missing, but they almost never identify for you which element(s) are missing when they reject an exam, making it nearly impossible to know what is expected. That said, it is clear from various audits that monocular entrance acuity, pupils, retinal findings (c/d ratio, macula, ON), SLE, refraction, monocular best corrected acuities, and tonometry are required. But what the "12 elements" are is not defined.
INTERMEDIATE EXAMS
VSP says they require the same Case History and the same Assessment and Plan for intermediate exams, but that an intermediate exam only requires 3 or more of the (mysterious) 12 elements to qualify as an intermediate exam. The manual does not specify any particular 3 that are required. Tonometry, however, is not as a failure to document tonometry leads to a comprehensive exam being downgraded to intermediate.
DIABETIC PATIENTS: SPECIAL RULES
VSP adds additional requirements for a diabetic patient.
First, they REQUIRE a dilated examination of the retina unless "the rationale for not performing dilation" is recorded in the chart. But that's not all. According to the manual, you are also -- required -- to "share" the dilated or retinal exam results with the patient's PCP.