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 headlights. You just have to keep asking the patient to elaborate, says the administrator. Soon something will occur to the patient, and theyll say, Yes, that is happening! and then you will start honing in on a solid chief complaint.

Tip: Dont forget to ask the patient about occupational issues, too. For example, perhaps the patient works at a computer and says he or she cant see it as well. Find out what the patient is referring to. Is the screen blurry? The letters on the screen? The colors? Is it difficult to distinguish the keyboard? And so on.

But the bottom line is that if there is no chief complaint, there can be no diagnosis or symptom reported. Without a diagnosis or symptom ICD-9 code the service is not medically necessary and will be deemed to be routine. Routine services are not a benefit of the Medicare program although some HMOs cover a routine eye examination periodically. It is unlikely that an optometrist would simply tell a patient that he or she had a cataract, without referring the patient to an ophthalmologist (in this case, the patient just went on her own, and told the ophthalmologist that she herself noticed no symptoms). But if you do get a report like this, Naberezny recommends that you try very hard to elicit as much information as possible before the examination, because if the patient does turn out to have a cataract, and had no chief complaint (other than what another provider told him or her), then you have a routine service which Medicare wont pay for.

Tip: There is a section in ICD-9 for subjective visual disturbances (368.1). All of these diagnosis codes are five digits. They are: 368.10 (subjective visual disturbance, unspecified), 368.11 (sudden visual loss), 368.12 (transient visual loss, such as concentric fading or scintillating scotoma), 368.13 (visual discomfort, such as asthenopia, eye strain, and photophobia), 368.14 (visual distortions of shape and size, such as macropsia, metamorphosis, and micropsia), 368.15 (other visual distortions and entoptic phenomena, such as photopsia, visual halos, and the refractive diagnosis of diplopia and polyopia), and 368.16 (psychophysical visual disturbances, such as visual agnosia or hallucinations).