Avoid Fraud:
Patient Complaint, Not Diagnosis, Should Drive Coding
Published on Sun Jul 01, 2001
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.
Triage by Receptionist and Technician 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.'" When There Is No Patient Complaint 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. [...]
