Ophthalmology and Optometry Coding Alert

Ophthalmology coders sometimes find that patients do not always have a chief complaint, at least not in the way that term is usually defined. But physicians can use the original diagnosis when billing follow-up visits.

For example, one coder notes that when she reviews charts, the ophthalmologist who sees glaucoma patients regularly to review medication and determine the progression of the disease does not have any chief complaints listed in the chart. Ive explained to my technicians that without the chief complaint, we cannot bill for a visit, the coder says. Their reply to me is that many patients do not have any visual problems and only come in because the doctor requested them to.

When the coder explains to the physician that she needs a chief complaint for billing purposes, he replies that a chief complaint is not necessary for glaucoma check-ups. I feel that we shouldnt be billing for these visits without a chief complaint, the coder maintains.

A chief complaint is actually the reason for the visit, which may not be a complaint per se, but may be patient here for follow-up for glaucoma, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C. According to CPT, a chief complaint is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patients words. Its enough to indicate the follow-up status of a known diagnosis as the chief complaint, Callaway-Stradley says.

Sharron Stevens, CPC, CCS-P, coding and reimbursement specialist at East Tennessee State University in Johnson City, agrees. On a follow-up for a previously diagnosed illness, you would use that diagnosis as the chief complaint, says Stevens, who codes for five ophthalmologists. As long as there is medical necessity for the visit, its okay to bill it.

Determining Medical Necessity

However, you cannot bill Medicare or most commercial insurance plans for the initial visit during which you first diagnosed the glaucoma unless the patient has a chief complaint other than the diagnosis that was made after the test. For example, a patient comes in for a refraction. I just want my eyes checked, the patient says. I have no problems. But you do a test and find there is glaucoma. Medicare wont pay for that initial visit, and neither will most commercial plans (unless patients have a vision plan as well).

If that patient says, Im feeling fine, and you find out the glaucoma condition is really bad, you still cant bill the initial visit, says Ronald Purnell, MBA, COE, administrator of Medical Eye Care Services in Worcester, Mass., where the subspecialty is geriatric ophthalmology. There has to be a patient complaint showing medical necessity for that visit, he says. Because you didnt know the patient had glaucoma before the visit, that cant possibly be the reason for the visit. There is no medical necessity.

Medicare uses the same reasoning regarding screening tests, including a screening test for glaucoma: You cannot use the diagnosis the test comes up with as the reason for doing the testyou must use the reason you ordered the test in the first place. If you ordered it to screen for glaucoma, there is no medical necessity. If you ordered it to see how the pressure is in a glaucoma patient, there is medical necessity.

But if you ask the patient to come back a month later to see how the medication is working and the patient still says, I feel fine, you can bill for it because you have a reason for the visit follow-up of glaucoma, says Purnell.

The complaint is that the ophthalmologist asked the patient to come back to check the known glaucoma condition. There is medical necessity for that visit. The patient isnt going to say, I feel pressure in my eyes, he says. The patient wont feel the glaucoma.

Except for in extreme circumstances, the patient wont have any subjective complaints from the disease, which is silent, says Purnell. The catch is that many ophthalmic assistants and technicians do not know that they should document the reason for the visit, follow-up for glaucoma, as the first entry in the chart. Once the glaucoma is documented in the patients chart, you can record what the patient reported about the status of the present illness, which is I feel fine.

Ophthalmologists should not use standing orders, an unwritten order for periodic services, medications or supplies, for these follow-up visits, however. If the ophthalmologist says, I want to see you in three months, thats fine, says Purnell, if the order for the return check-up is documented in the medical record. But the doctor cant say to the patient, Come in every three months. Medicare wants the doctor to make the decision each time, based on the patients status. You cant have a standing order with Medicare.

Commercial carriers dont like standing orders either, says Stevens. In ophthalmology, commercial plans request records often, she says. Its hard to determine medical necessity if you have a standing order. Because commercial carriers usually follow Medicare rules when it comes to medical necessity, Stevens urges ophthalmologists to stay away from standing orders.