Advanced Search

Ophthalmology and Optometry Coding Alert

Avoid Being Caught in the No Reason Diagnosis Coding Trap

Published on Tue Jul 01, 2003

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 scarring (371.0x, Corneal scars and opacities), which you could use in the diagnosis pool.

Scenario 2: Routine vs. Complaint-Generated Exams

There are some caveats to coding chief complaints for routine exams. For example, patient P.W., age 68, presents for his routine eye examination. Although he mentions no specific complaint, during the exam the ophthalmologist diagnoses early glaucoma. When a beneficiary with no specific complaint undergoes an eye examination by the ophthalmologist, the expenses for the examination are not covered, even if the physician discovers a pathologic condition during the exam. This lack of coverage is because Medicare's Routine Services Policy states that "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." So if, during the routine service, the physician diagnoses one or more conditions, the initial visit is still not covered.
 
When coding for routine services, it is easy for coders to mistakenly use the diagnosis code for the condition(s) that the physician documents during a routine service, such as early cataract or dry-eye syndrome, Duran says. For the Medicare carrier to properly process the claim (to result in a denial for a noncovered service), use the diagnosis code V72.0 (Examination of eyes and vision). If you use a refractive error diagnosis code instead, the claim will be denied for lack of medical necessity, she says.
 
Note: When a Medicare 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, even if the physician only prescribes eyeglasses.
 
Scenario 3: Patient Can't Communicate

Sometimes a patient presents who is unable to effectively communicate problems she is having. For example, patient R.T., age 83, with early Alzheimer's, presents with her caregiver for an examination. The patient is unable to voice any complaint and seems confused about why she is being examined, so the ophthalmologist must depend on the caregiver to relay information about the reason for the visit.
 
This is another situation that makes it difficult to code a chief complaint when working with Medicare patients, Lange says, because the patient cannot communicate any reason for the visit. In these instances, you should document the patient's inability to converse and obtain the reason for the visit from the caregiver or person accompanying the patient, says Erica Kuntz, CPC, COA, in Ohio. Documentation clarifying the patient's condition and signs or symptoms from the facility where the patient resides are also useful, she adds. Lange says that in her experience, good documentation obtained in this manner is sufficient to code the chief complaint and prove medical necessity for the exam.

Scenario 4: Use the Previous Diagnosis

Some circumstances can arise that require reporting a patient's previous diagnosis and linking it to a return visit. For example, patient B.W., age 70, is undergoing care for glaucoma (365.11, Primary open angle glaucoma). The ophthalmologist notes that the patient's intraocular pressure (IOP) is not satisfactory and wants B.W. to try another kind of eyedrops. In his management plan, the ophthalmologist recommends that B.W. return in two weeks, after switching eyedrops, for another IOP check. If the patient's IOP is still not satisfactory at that time, the ophthalmologist documents that other treatment methods will be discussed.
 
At the two-week exam, the ophthalmic technician finds that B.W. is tolerating the new eyedrops well and not experiencing any discomfort; however, his IOP is still 2 mm above the desired range sought by the ophthalmologist. The impression or assessment for the visits notes these facts, and because of the still-high IOP, the physician recommends that the patient return for laser treatment. In this case, coders should use the same diagnosis as the original exam when coding these return exams and code to the most specific level possible, Lange says.
 
You can use the patient's previous visit as a chief complaint, she says. For example, "Patient returns at doctor's request for evaluation, status post-corneal transplant." The diagnosis could be any one of the "status post" codes, in this case, V42.5 (Organ or tissue replaced by transplant; cornea), although some carriers balk at paying for V codes.
 
The patient's chief complaint or previously diagnosed condition determines the medical necessity of the exam, Kuntz says. She gives this example: A patient presents complaining of seeing flashes of light and is diagnosed with posterior vitreous detachment (379.21, Vitreous degeneration). The ophthalmologist asks the patient to return in 10 to 14 days for a recheck, to watch for retinal detachment signs and symptoms. At the follow-up exam, the patient does not report an increase of the flashes of light or other new symptoms. This exam is still medically necessary because of the previously diagnosed condition.

Other Articles in this issue of

Ophthalmology and Optometry Coding Alert

View All