Ophthalmology and Optometry Coding Alert

Be Smart About Coding Chief Complaints

Coding a patient's chief complaint may seem easy and clear-cut, but what about the patient who presents for a routine exam without a chief complaint, or the patient who returns at the behest of the physician but is not voicing any chief complaint? These special situations require careful diagnosis coding if you want to justify payment for services.
 
Suppose, for example, a patient presents for a return visit and says, "My eyes seem OK, but I'm here because the doctor asked me to return in three months." How do you translate this statement into a chief complaint whose diagnosis code will be covered for the follow-up visit?
 
An E/M type of service requires a chief complaint, which the E/M documentation guidelines define as "a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words."
 
Let's look at some difficult scenarios that depict office visits, and discuss how you should code the reason for the visit:
Scenario 1: Physician-Ordered Return Visit
A new patient, J.H., age 68, undergoes a retinal detachment repair 67101 (Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid). A postoperative exam indicates no further detachment or residual holes. Nevertheless, the ophthalmologist asks her to come back in six months.
 
J.H. returns for the exam six months later, as directed. She says she has no problems with her vision, so at first, it appears that she has no chief complaint. If a physician-recommended follow-up, problem-free visit is truly the reason for the visit for example, "Patient here for follow-up of retinal detachment surgery" then documentation should state any complaint or lack of complaint from the patient.
 
The case of a returning Medicare patient who has perfect vision would be extremely unusual, says Fiona Lange, CPC, coding specialist with Danbury Eye Physicians in Connecticut. As her physicians have stated, "It is a very rare Medicare patient who has perfect eyesight." Common conditions include previously diagnosed nuclear sclerosis (366.12, Incipient cataract) or other age-related diagnoses, such as 362.51 (Nonexudative senile macular degeneration) or 375.15 (Tear film insufficiency, unspecified), says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. These conditions were often documented in a previous examination and are the reason the patient was directed to return for a follow-up examination.
 
Medicare patients frequently have a concurrent condition, even if their status is postretinal or corneal transplant surgery, Lange says. She says these Medicare patients could likely still have a floater (379.24, Disorders of vitreous body; other vitreous opacities), vitreous detachments (379.21, Disorders of vitreous body; vitreous degeneration), or some corneal [...]