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 [...]