Ophthalmology and Optometry Coding Alert

Use this field-tested checklist to make your work more efficient and more effective

Coding is part art form, part mechanics. Successful coding requires creativity at times and a consistent attention for detail. By mastering certain basic practices - and making them second nature - you'll be ahead of the game when it comes to beating the odds on reimburse-ments and appeals.

Use the checklist below to organize all the elements required for correct coding:

1. Keep charts neat and complete. Encourage all practice personnel to keep legible, clear charts. Maintain a "Most Wanted" file that highlights commonly used codes that require additional documentation or support materials - and make sure office personnel are aware of these.

2. Sweat the small stuff. "Really be aware of those modifiers, of which modifiers to use," says Christine Fitzgerald, CPC, accounts manager for The Rhode Island Eye Institute. Why, where, and when do you need to use those little add-ons? Understanding your carriers' rules about how to use modifiers can increase your reimbursement potential.

3. Strive for the most detailed diagnoses you can. Fourth and fifth digits will help you code correctly for billing purposes, and, more important, they provide you with a greater capacity for patient tracking and disease management.

4. Always base coding on medical record documentation. Be fanatical about reviewing documentation to be sure the record supports the codes selected. It helps tremendously to have all of the patient's documentation in front of you so you can make the proper choices while you're coding.

5. "Never assume!" If you have a question about a code or a comment your physician has made in a patient's record, do not assume what she meant. Guessing or submitting paperwork you don't feel comfortable with will come back to bite you. "Never assume, never assume - question it," another expert says. You might help catch an oversight by the physician (that you will have to deal with later), or you might learn something new about a diagnosis or procedure.

6. Check and keep a record of carrier updates. Stay consistent with updated information: new ICD-9 codes, new NCCI edits, carrier bulletins, and explanations of benefits (EOBs). Staying current with this new information will give your practice a leg-up on the road to new opportunities and out of the noncompliance ditch. Most updates come on a regular schedule, so mark your calendars to remind yourself to read these immediately upon release.

A quick scan can tell you whether something new is relevant to your practice or specialty. Share key updates, journal articles or other specialty-specific material with your billing staff to support tricky codes. And don't forget to stamp a date on those releases and store them chronologically for easier reference, says Nancy Cockrell, insurance and billing coordinator for Jackson Eye Associates in Mississippi.

7. Run system reports to discover claims with invalid codes. Once new codes take effect, you need to find existing patients with codes that are no longer valid and correct the codes. This is another activity you can schedule based on the ICD-9 and NCCI release calendar.

8. Document information on (upcoming) new codes. In addition to revising the old codes, anticipate the new. Being familiar with your carriers' local medical review policies (LMRPs) on new services will help you understand what documentation will be required once a new edit goes into effect. The draft versions of these LMRPs are usually available for some time before the actual change. Take note of the effective date for the new codes, as well.

9. Know thy carriers. Your local Medicare carriers and private insurance companies will all have their own ways of doing things. Note what they accept, what they deny - and why. What documentation do they require to approve claims? Study denials AND approvals for tips on what works with whom. Keep a cheat sheet that notes any special coding instructions you should use to maximize payment and minimize denials.

10. Really know thy carriers. Call them; learn their names. Establishing relationships with your local carriers, medical directors and insurance representatives can be critical to steering around trouble in the road and understanding upcoming policies, Cockrell says. CMS regulations and medical advances can hit quickly for all of us. The closer you are to the people translating and enforcing the rules, the better your chances of having a voice in the decision process.