Ophthalmology and Optometry Coding Alert

By working with clinicians, you can decrease the burden on all staff members.

As eye care practices work to comply with not only CPT^® and ICD-10 requirements, but also the government quality measures that are growing in importance, it's essential to ensure that your clinical documentation meets the government's requirements. Add to that the fact that more than 25 percent of adults have two or more chronic conditions, and your documentation can be a challenge.

However, if you work carefully with support staff and clinicians, you can get a handle on the requirements and even help improve your reimbursement, advised Rhonda Buckholtz, CPC, CPMA, CRC, CDEO, CPC-I, CHPSE, COPC, vice president of strategic development for Eye Care Leaders, during her Dec. 13 webinar, "Navigating Changing Healthcare Environments Through Clinical Documentation Improvement webinar." Read on for three essential tips that she shared during the presentation.

1. Clinician Engagement Boosts Documentation Precision

Engaging all staff in the documentation process doesn't just take the heat off the office manager – it increases compliance and makes documentation more precise, Buckholtz said.

She points to a recent study showing that if you can engage with the clinician and work on ways to marry meaningful documentation concepts with the conditions they're treating, practices can meet or exceed meaningful use rules for documentation compliance in terms of the quality measures for E/M levels and surgical procedure documentation.

"We saw that it actually began to reduce the administrative burden for physicians," Buckholtz said. "So instead of teaching the physicians how to count bullets or making sure they document other key concepts that aren't always related to the patient experience or the outcome of the patient's clinical condition, being able to teach them to change their documentation and to work with that has been very strategic for us in simplifying the process."

This makes practices much more compliant, especially in today's audit-heavy environment, she said. "And it also helped increase revenue streams because we were able to make sure the physicians captured everything they were doing in a meaningful manner."

Nailing down great documentation habits now can help your practice down the road, whether the quality measures remain the same or change, Buckholtz said. "At the end of the day, I don't care what quality measure wins, how we're going to report it or what new, unique, reporting requirement they're going to have. If we can work on those documentation concepts and really template those strategies and teach scribes, techs, and front desk staff why what they're doing is important and how it impacts everything -- then it doesn't matter what initiative wins at the end of the day. You're covered no matter what."

Work on These 7 ICD-10 Concepts

If you review the 22 or so unique clinical concepts in ICD-10 and look at them from an ophthalmology standpoint, it's easy to identify the factors that are most important for identifying the right ICD-10 code, Buckholtz says. They are as follows:

• The type of condition
• Temporal factors
• Caused by or contributing factors
• Any symptoms, findings, or manifestations
• The localization or laterality
• Anatomical location
• Associated with or severity.

"Those are the main ones," Buckholtz said. "Sometimes episode comes into play, but these seven are very beneficial for templating or education purposes," she said. "So you want to make sure you always have a way to capture all that information and this is an area where you can get some really good engagement."

By streamlining the ICD-10 documentation concepts, you can work with staff when scheduling to capture the required information, and you can also create templates and configure EHRs, she said. It also helps take burden off the physicians so they can return to providing true health care, she added.

"In ophthalmology we don't see patients with 20, 30, or 40 different clinical conditions. Typically they're related to the same ones, so it becomes a little bit simpler to document," she said. Make as many templates as possible for the conditions you're treating rather than limiting yourself to one or two, she said.

3. Document Interpretation and Report

In addition to documenting diagnosis and procedure codes thoroughly, remember to record the orders and results for diagnostic testing, as well as interpretations and reports, when applicable.

"One thing we're seeing a lot in the marketplace right now is audits on diagnostic testing," Buckholtz said. "All of those diagnostic tests require some level of interpretation and report. Unfortunately, just pulling the data in from those tests does not constitute an interpretation and report, that's just the results. So you really want to look at those and find those types of things," she said.