Ophthalmology and Optometry Coding Alert

One of the hardest coding truths an ophthalmologist has to swallow is the one about rule-outs: You cant code for something if the patient had no symptoms and you didnt find the condition. Marcia Carlsen, office manager for Thomas C. Black, MD, FACS, of Kansas City, MO, writes to ask, What is the best way to code when you are trying to rule out a condition, and you find nothing wrong? In this case, the patient thought an optometrist had told her that she had cataracts, and went to Black in a panic. She had no symptoms of cataracts, according to Carlsen. While the patient was very relieved to find out that she had no cataracts, Carlsen was left to wonder how to bill for the visit. When an ophthalmologist takes the time to evaluate a patient for cataracts, Carlsen says, but finds nothing, what can he bill for?

The real question isnt what the doctor finds, but what the patient is complaining of, says Mary Ann Naberezny, administrator of South Hills Eye Associates, a four-ophthalmologist, one-optometrist practice in Pittsburgh, PA. If the patient comes in with no complaints, and you do find something in the exam, you still cant bill for what you found, the administrator explains. Lets say you find a cataract but the patient had no complaints. The cataract has to be the secondary diagnosis, not the primary one.

The primary diagnosis would be whatever did bring the patient to your office. For example, if the patient comes in with a complaint of a foreign body, and the ophthalmologist finds a cataract, the foreign body must be the primary diagnosis. The chief complaint has to be reflected in the ICD-9 code submitted, says Naberezny.

Basically, the chief complaint and the ICD-9 code have to be the same thingthe chief complaint in the patients words may be described as symptoms versus the diagnosis which is the clinically correct term for an abnormality found.

Chief Complaint Necessary for Reimbursement

This is why the interview done by the technician before the ophthalmologist sees the patient is so important. Youve got to triage the patient really well, explains Naberezny. A lot of patients dont want to talk to the technician; they want to wait and talk to the doctor. Yes, the ophthalmologist theoretically can get the information as well. But it takes a lot of time, the administrator says. Its better for the technician to get it.

So, the technician has to be able to encourage the patient to talk. Lets say the patient says theyve quit driving at night, says Naberezny. You have to get them to expand on this. For example, you can ask the patient if there is glare from the [...]