Don't shortchange yourself. Learn the nuances of CPT codes and documentation for proper reimbursement.
Glaucoma is one of the leading causes of irreversible blindness in the United States. About 3 million people currently have the disease and another 1.5 million will be diagnosed this year, leading to 7 million examinations in eyecare offices.
As you know, glaucoma can be difficult to manage, and patients' responses to treatment and progression can vary significantly. Thus, coding for glaucoma services can be confusing. In this article, we'll sort out some of the commonly misunderstood issues related to coding and reimbursement for glaucoma.
Medicare will reimburse ophthalmologists for any level of evaluation and management (E/M) service or eye code supported by medical necessity and documentation in the patient's chart. Optometrists are guided by local carrier policies that sometimes preclude the highest levels (4 or 5). See the chart below for utilization rates.
Basic charting rules apply, such as:
* Notes must be written legibly in ink.
* Each visit should stand alone.
* Each page should have the patient's name, date of service, subjective notes, objective findings, assessment/impression and plan/treatment (SOAP note).
* The provider should sign each entry.
Be sure to identify and document significant positive and negative findings. The old adage, "If it isn't written down, you didn't do it!" is truer than ever.
Although poor documentation results in reduced reimbursement, the converse doesn't necessarily follow. The nature of a disease or abnormality imposes an upper limit on the level of service, so extraneous notes are valueless in the context of reimbursement.
The chief complaint, an essential part of every chart note, is a brief description of the reason for a patient's visit. Medicare requires that you report a patient's chief complaint to render the visit a covered service.
The Medicare Carriers Manual (MCM), Part 3 §2320 reads:
The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.
Glaucoma patients rarely have symptoms, so the chief complaint in their charts is often weak, at best. Chart notes often begin with "no problems," "doing well," "no change from last visit" or simply "recheck." These phrases are problematic from a reimbursement perspective.
Doctors have the right and the obligation to follow a patient with a chronic disease, and Medicare always covers return visits for chronic diseases. Therefore, an entry, such as: "4-month follow-up for chronic open-angle glaucoma (COAG) per Dr. Smith" or "3-month IOP reevaluation for combined mechanism glaucoma (CMG)," justifies a covered service and clearly states the reason for a visit. Part of the entry may be "doing well" or "no change from last visit," but the initial statement is critical.
Now, the issue becomes the code you should choose at the end of the visit. You can select from five levels of E/M services or two levels of General Ophthalmological Services (eye codes). To find the appropriate code for every patient, you must gather key information over the course of a patient encounter.
Defining the patient encounter
The three vital components of a patient encounter for E/M code documentation are history, examination and medical decision-making. You must meet specific requirements to complete each component, specifically:
* History must include: A history of the present illness (HPI); a review of systems (ROS); and past personal, family and social history (PFSH). See "Taking a Patient History" for a more in-depth description of these essential elements.
* Examination includes 12 elements from which you can choose, depending on the patient's complaint and condition. For a list of these elements, see "Examining a Patient."
* Medical decision-making involves the number of diagnoses or management options; the amount or complexity of diagnostic tests or other information; the risk of complications, morbidity and/or mortality. For more on this important aspect of the patient encounter, see "Making Medical Decisions."
After gathering data to fulfill the three key components of a patient encounter, select the appropriate current procedural terminology (CPT) code. For new patients and consultations, you must meet or exceed all three components of a patient encounter. For established patients, you must meet or exceed only two of the three key components. See the charts below for a list of appropriate CPT codes.
Ensuring successful patient encounters
Coding mistakes can arise from errors committed at any stage of patient evaluation. Here are some pitfalls to avoid.
The HPI significantly contributes to E/M code selection. Capturing enough information in a predominantly asymptomatic disease like glaucoma can be challenging. Given that glaucoma is time- and treatment-dependent, the following examples illustrate useful notations that help you provide appropriate care and withstand post-payment scrutiny by the payer.
1. Chief complaint: 4-month IOP reevaluation for COAG per Dr. A. HPI: COAG OU, R>L, x 11 yrs. c/o ++ redness post instillation of gtts x 30 mins. (Location, severity, duration, quality, timing)
2. Chief complaint: 6-month combined CMG reevaluation, per Dr. K. HPI: CMG OU, x 16 yrs. c/o poor compliance due to forgetfulness. Using gtts, = qod not qd. (Location, duration, quality, modifying factor, timing).
Not all HPIs contain four or more elements, but you should strive to include at least four.
For new patients, a comprehensive ROS is customary. On follow-up, the ROS is often, but not always, unchanged. When a patient has significant health changes, such as new chronic systemic disease or progression of an existing illness, a fresh ROS notation is justified. If the patient reports no changes, it's sufficient to state in the examination notes, "no ROS changes since X/XX/XX."
Falling under the category of PFSH, you should document any side effects, such as shortness of breath, dizziness or headache, which can be caused by anti-glaucoma medications. Although glaucoma is a heritable disease, information about family and social history is seldom as critical or as changeable.
Determining service levels
Because of the frequency of patient visits, the level of service for a glaucoma examination isn't always the same. The examination level should be based on:
* Length of time since the last visit
* Other related or contributory diseases
* Changes in the patient's history or chief complaint
* Changes in clinical findings
* Reason for current visit.
Disease progression usually warrants a higher level of service than stable disease.
Forming a treatment plan
A standard SOAP note includes a notation about a patient's condition or diagnosis. To take your charting to the next level, include information about the type, severity and location of glaucoma as well as disease progression or stability. A diagnosis of "glaucoma" isn't sufficient to select an accurate ICD-9 code.
Ordering tests is an essential part of managing glaucoma. Document any requested tests and results in the patient record, usually in the plan. Accurate notes support your level of service in addition to recording your next intended step or visit.
Assessment and planning - the most subjective portion of the E/M system - determines the level of risk. The clearer your chart notes, the easier to determine risk. Make certain your thought processes are documented. For instance, if your patient has primary open-angle glaucoma (POAG) and an autoimmune disease such as rheumatoid arthritis with secondary iridocyclitis, she's likely taking anti-inflammatory medication, which can exacerbate the POAG. To support the higher risk level, note in the chart why treating this patient is significantly more complicated than treating someone with a single disease. Your records also will justify repeated visits as well as potentially higher levels of service.
Using eye codes
Depending on the situation, you have at least two choices to describe eye examinations: Ophthalmology (eye) codes or evaluation and management (E/M) codes. The five levels of E/M codes are universally applicable for all manner of ailments; yet, they're complicated and necessitate at least two pages of documentation for a comprehensive exam.
Eye codes are suitable for most eye diseases and conditions, except for very simple cases and the most complex assessments. Eye codes have simple definitions and are limited to two levels of service, so they're easily understood, and required chart documentation readily fits on a single page. Therefore, you may prefer to use an eye code instead of an E/M code, especially when you consider that services described by eye codes usually are reimbursed at a higher rate than those described by E/M codes.
A few payers deem eye codes the province of optometrists and routine eye care. This arbitrary rule is a minority view and has no basis in CPT. When the payer won't accept your initial claim, it's helpful to translate an eye code to an E/M code, or vice versa. Using this so-called crosswalk is a useful way to receive reimbursement for your services.
Eye code requirements
Documentation requirements for eye codes, compared to those for E/M codes, are much easier for most practitioners to meet, especially the history requirements. The chief complaint is still key to Medicare coverage, but HPI, ROS and PFSH aren't crucial in determining the level of eye code.
Eye codes won't cover every possible situation, but they're adequate for most examinations. You'll still need to use E/M codes for complex or very difficult cases.
CPT recognizes that eye codes work on a different principle from E/M codes, particularly with regard to the components of an examination:
Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision-making cannot be separated from the examining techniques used. Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry or motor evaluation is not applicable.
Most Medicare carriers have published policies that follow CPT very closely, although a few have stated that some components are required for a comprehensive examination. In particular, several Medicare carriers have adapted the numerical elements of the E/M guidelines to eye codes. These carriers specify eight or more elements for a comprehensive eye examination (92004, 92014) and three to seven elements for an intermediate eye examination (92002, 92012). Check your individual carrier's policies on eye examinations.
Eye code visits are either comprehensive or intermediate for both new and established patients.
* 92002. Ophthalmological services: Medical examination and evaluation with initiation of diagnostic treatment program; intermediate, new patient.
* 92004. Ophthalmological services: Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.
* 92012. Ophthalmological services: Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.
* 92014. Ophthalmological services: Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
Medicare defines a new patient as one who hasn't received any professional services from the doctor or another doctor of the same specialty in the same group practice within the past 3 years.
Comprehensive codes (92004, 92014) describe a general evaluation of the complete vision system. According to CPT, the code:
. . . includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.
Note that gross visual fields and basic sensorimotor examination (extraocular movements) are required for a comprehensive eye examination. Interestingly, other elements of an examination that most practitioners would expect to include aren't required. Dilation is listed as optional in the CPT description, although some Medicare carriers have published policies stating it's a required procedure.
CPT comprehensive codes are used to describe a single service that need not be performed at one session. In other words, you may "bridge" an examination over more than one session in a day (morning and afternoon) or more than one day (start today, complete the examination tomorrow). Often, this happens when a patient declines to have his pupils dilated during an initial examination and returns at another time to complete the dilated examination. In this situation, you should submit one claim and document in the patient's chart that the examination extended over a certain time, usually no more than a day or two. A bridged examination doesn't apply to E/M services.
Intermediate codes (92002, 92012) are defined as:
. . . an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy.
As with comprehensive visits, dilation is optional.
Many follow-up examinations for chronic, stable conditions don't qualify as intermediate eye examinations (92012) because they don't include a new condition or an existing condition complicated with a new diagnosis or management problem. Under these circumstances, particularly for glaucoma care, your only option is to return to E/M codes and choose an Expanded Problem Focused (EPF, 99213), or Problem Focused (PF, 99212) exam.
Although you may make periodic adjustments to glaucoma treatment or encounter new complaints, many follow-up visits determine that a patient's disease is stable. Your final diagnosis may read "POAG R>L - stable," which precludes the use of the intermediate eye code. It's important to emphasize that the "new problem" doesn't necessarily relate to the primary diagnosis. When a patient has a chronic illness, it's easy to forget he can develop another acute or chronic condition. New problems usually appear in the patient complaint, but because the focus is on the patient's chronic disease, the new disease may be missed. You should pay particular attention to the patient history, even for a routine follow-up.
Some glaucoma patients who don't respond to IOP-lowering medications may need surgery. As an optometrist, you may be involved in postoperative care and have questions as to when the visits are billable.
If you're a member of an M.D./O.D. group and one of the group's surgeons performs the glaucoma surgery, you and the other members of the group are bound by the global surgery rules. Therefore, visits during the postoperative period are included in the global fee unless the reason for the visit is unrelated. For argon or selective laser trabeculoplasty, this period is 10 days, and for all other glaucoma surgeries the postoperative period is 90 days. If you need to treat the patient for an unrelated condition during this time, the appropriate level of service should be billed with a -24 modifier.
If you're not a member of an M.D./O.D. group, your ability to charge for postoperative visits changes. Comanagement for glaucoma surgery is rare, but if this situation arises, the number of days you assume postoperative care determines your reimbursement. Individual visits aren't billed. Instead, you should use the surgical CPT code with a -55 modifier for the total number of postoperative days you treated the patient.
In the absence of a comanagement agreement, you'd see the patient for postoperative care and charge for the appropriate office visit each time you see the patient.
Examining your options
Successful reimbursement depends on keeping detailed patient records and translating this documentation into appropriate CPT codes. Understanding your billing and coding options increases your potential for maximum payment.
Patricia J. Kennedy, C.O.M.T., C.O.E., C.P.C. & Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O.
Copyright Boucher Communications, Inc. Dec 2003
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