Ophthalmology and Optometry Coding Alert

Using specific diagnoses codes, documenting legibly and knowing when to use consultation codes are important objectives for ophthalmologists to avoid denials and potential audits. There are many mistakes that can be made in coding ophthalmology claims, but there are some areas that cause more trouble than necessary. Ophthamology coders who are constantly refiling claims need to cut out the problem areas to prevent denials in the first place. The possibility of facing an audit is even more detrimental to an ophthamology practice. Would your documentation stand up to an audit? If not, you might have more to worry about than the cumbersome task of reprocessing claimsthe practice may have to refund money and even pay fines.

Below are some very common coding errors.

1. Using nonspecific diagnosis codes. The more specific the diagnosis, the more likely the payer is to pay with the first claim. For example, you should use a specific glaucoma diagnosis code, not a nonspecific one. Patients are often seen first with a diagnosis of glaucoma suspect, says Lise Roberts, vice president of Health Care Compliance Strategies, a coding, compliance and reimbursement consulting firm in Syosset, N.Y. Even this early finding has options for coding to the fifth digit. The code to avoid in this range, if possible, is 365.00 (preglaucoma, unspecified). Codes that give more information would be 365.01 (open angle with borderline findings), 365.02 (anatomical narrow angle), 365.03 (steroid responders) and 365.04 (ocular hypertension).

Once a definitive diagnosis of glaucoma is made, a specific glaucoma diagnosis should be used, Roberts notes. Do not use code 365.10 (open-angle glaucoma, unspecified) because it is not specific enough. More precise codes include 365.11 (primary open-angle glaucoma), 365.12 (low tension glaucoma), 365.13 (pigmentary glaucoma), 365.14 (glaucoma of childhood; infantile or juvenile), or 365.15 (residual stage of open-angle glaucoma). In the early diagnosis and treatment of a glaucoma patient, visits occur more frequently. The specific diagnosis coding helps to make the medical necessity for the frequency of the visits more clear.

And its not enough to just have the code rightthe documentation needs to support that code. If its not specified even in the documentation, you have a problem from a compliance standpoint, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. a coding, compliance and reimbursement consulting firm in Spring Lake, N.J. The ophthalmologist may have checked the right code on the superbill, but if its not specified in the documentation, its not adequate, she says. Another problem occurs when the documentation is correct, but the superbill is wrong, says Brink. If the ophthalmologist documents a specific cataract in the record, but checks off a nonspecific cataract code on the superbill, thats a problem as well, she says, adding, You shouldnt have nonspecific codes on the encounter form anyway.

2. Illegible documentation. From a compliance standpoint, the physician needs to study proper documentation, says Brink. And legibility is always a problem. Because ophthalmology documentation is so complicated, she says some type of ophthalmology form or template should always be used for this documentation. Also, often a technician or a scribe will actually write the documentation. This is fine as long as certain rules are followed, says Brink. Whether the documentation is done by a scribe or technician, the physician signs off on it. When the physician signs the bottom of the chart, that becomes his or her work, says Raequell Duran, president of Practice Solutions, a coding and reimbursement consulting company in Bakersfield, Calif. The physician is responsible for the accuracy of the documentation, says Duran. This is different from a teaching setting, in which the physician must make a substantial note in addition to what the resident documented.

3. Billing consultations incorrectly. There is still a great deal of confusion about when to use the consultation codes. On the one hand, if you err too much on the side of caution, you will not be billing them when you should and losing deserved revenue as a result. On the other hand, if you bill them when you shouldnt, you will be running afoul of the Health Care Financing Administration (HCFA), risking getting flagged for an audit, triggering an audit, and failing an audit. In 2000 you no longer need a written request in order to charge a consultation, says Brink. But that doesnt mean every new patient you see is a consultation. First of all, there must be a request for a consultation by another physician. Second, either the referring physician or the consulting physician must write a note in the record stating that there was a request for the consultation. As Roberts puts it, Since you dont know whats in the other guys documentation, youd best make sure its in yours if you are the consultant. Brink counsels her clients to keep the word referred out of their charts altogether, unless it is clear that a transfer of care is taking place. Referral means transfer of care to many payers, so dont write, Patient was referred to me for a foreign body sensation, she says. Instead write, I saw this patient at the request of Dr. X. Finally, you must send a written comment back to the requesting physician.

In addition to documenting the request for the consultation, the consulting physician must provide a written report of his or her opinion and advice back to the requesting physician, notes Roberts. This is usually done in the form of a letter but could also be in the form of progress notes in the case of an intra-group consultation with a shared medical record. With a letter, it is assumed that the requesting physician has received the benefit of the consult because he or she has received the letter. The same is not true of progress notes, so once the consultation note is completed, the chart must be routed back to the requesting physician, who must review the note and make a dated entry to that effect. This is the only evidence that the report was sent and received. Some practices even have a special consultation sheet on a colored piece of paper that is used for intra-group consultations. This makes such services easy to visually identify in the medical record.

Note: For more on consultation coding, see articles, Medicare Transmittal Clarifies Consultation, in the November 1999 issue of Ophthalmology Coding Alert (OPC), Get Compensated for Consultations: Document and Code Appropriately, in the March 1999 issue of OPC and Improve Reimbursement for Consults and Special Services on the Same Date, in the April 1999 issue of OPC.