Ophthalmology and Optometry Coding Alert

Ophthalmologists choose diagnosis codes based on the patient's condition, but whether the visit is payable depends on the patient's complaint or, as Medicare phrases it, "the patient's reason for the visit." If ophthalmologists don't follow Medicare's rules on diagnosis coding and the chief complaint, they risk having to make a refund to Medicare or face audits. If you have a pattern of such claims, you could be accused of fraud.

This area presents complications for ophthalmologists because the technician normally conducts an extensive interview to elicit a chief complaint, but sometimes that complaint (or lack of complaint) conflicts with the diagnosis. For billing, it doesn't matter what you find in the examination. If the patient says he or she has no problems, you cannot bill Medicare for the visit.

HCFA created a special rule to avoid paying for routine exams. You can bill only if the patient presents with signs or symptoms, known diagnostic conditions or for a physician-recommended return. The patient must have a complaint or known condition.

 

A good technician can discover a problem. Receptionists should perform triage to determine why the patient needs an appointment. If the patient says, "I just want to see the doctor," the receptionist scheduling the appointment should ask, "What made you want to see the doctor today?" This usually elicits something that can be used in the history to show medical necessity, says Lise Roberts, vice president of Health Care Compliance Strategies, a consultancy based in Jericho, N.Y. "Patients don't usually just wake up in the morning and say to themselves, 'I think I'll go see an eye doctor.'"

 

 

Sometimes a patient is determined not to explain the reason for the visit until he or she sees the doctor, so the staff should leave the chief complaint and history of present illness blank. "This should be the signal to the doctor that he or she needs to obtain additional information from the patient," Roberts says.

"We have a list of questions that start with night and day vision," explains Winnie Kilbase, administrator with Retina and Vitreous of South Bend, Ind. "We ask about focusing on things at a distance. The doctor establishes the findings and treatment plan, but we do attempt to get the chief complaint first." 

Another solution is for the office staff to let the patient know that if there is no medical reason to see the doctor, the service is not a benefit of the Medicare program. The explanation should inform the patient that he or she would have to pay for the service. This often elicits the information the patient was withholding earlier.

 

 

Diagnosis related to complaint: Sometimes the patient has a complaint but the physician finds that the explanation for the complaint is a definitive diagnosis. For example, the patient complains of blurry vision (368.8), and the ophthalmologist finds cataracts (366.xx). "I would code the cataracts as the primary diagnosis, and the blurry vision secondary," says John S. Bell, administrator and CEO of Maine Eye Care Associates, based in Waterville. This is a payable visit because there is a complaint and a payable diagnosis.

Diagnosis unrelated to complaint: Use a sign or symptom diagnosis code when there is no definitive diagnosis related to the complaint, Roberts says. "If the patient's chief complaint is not related to the definitive diagnosis that applies, code the sign or symptom as primary and the other nonrelated diagnosis code or codes as secondary." Medicare requires that the primary ICD-9 code be either the sign or symptom or the definitive, related diagnosis, she says.

For example, a patient complains of red, irritated eyes (379.93), and the physician also finds cataracts (366.xx). Even though the cataracts may be a worse problem, the diagnosis related to the patient's chief complaint must be listed as the primary code.

 

 

Sometimes the ophthalmologist finds a problem but there is no patient complaint. The best example of this coding dilemma is the glaucoma patient, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding consultancy. Screening a  patient for glaucoma, if that is the only reason for the visit, is not covered at this point. "Even if a patient schedules an appointment due to 'family history of glaucoma,' the visit is not a covered service," she says. "You cannot be paid, even if you find glaucoma during the screening examination." 

For instance, the patient schedules an office visit for a routine examination and eyeglass check, and denies any complaint when asked about visual problems. During the visit, the physician finds that the patient has glaucoma. This visit, when the patient is diagnosed, is not covered and should be coded V72.0  (examination of eyes and vision) or V70.9 (unspecified general medical examination), Duran says. The next time the patient is seen, however, the visit is covered, because the patient is being seen for a known condition, and for a physician-recommended return. 

In another example, a physician finds a retina blastoma -- a serious condition that can require removal of the eye -- during a screening examination. If the patient presents with no complaint and can think of no sign or symptom he or she has that would be considered related to the retina blastoma, the patient would have to pay for the visit, Roberts says. The visit will be considered "routine" by Medicare. 

 

Sometimes the patient presents with a problem, but the physician finds nothing. You can bill for this visit.

"Whatever the patient complains of, that's what you code," Bell says. "Let's say they have blurry vision -- it could be cataracts, it could be a refractive error, it could be nothing. Code blurry vision (368.8) in this case. It's payable by our Medicare carrier." Bear in mind that not all local medical review policies cover blurry vision as a diagnosis in all carrier jurisdictions.

In another example, the patient complains of floaters -- seeing a spot in the vision of the eye. The physician completes a dilated examination, including extended ophthalmoscopy. There is no posterior vitreous detachment and no retinal detachment, and not even a vitreous floater is seen. In fact, no pathology is found at all. The ophthalmologist advises the patient to return if new floaters or other visual changes occur. This visit is billed based on the patient complaint (368.10). The office visit is billable because the patient had a complaint. However, the ophthalmologist could not bill for the extended ophthalmoscopy. Charging that requires a diagnosis of a vitreous floater (379.24).