Ophthalmology and Optometry Coding Alert

Eye care practices that make this error could see an uptick in claim denials.

You’ve heard the term “medical necessity” hundreds of times during your coding career, but do you really know how it impacts your revenue? The answer may surprise even the most seasoned coders.

The terms “medical decision-making” (MDM) and “medical necessity” are sometimes used interchangeably, but there are vast differences between the two. MDM can help you select the correct E/M code level, but it’s medical necessity that will allow you to collect for all of your services. Ensuring that your charts include documentation of medical necessity for the visits that your eye care physicians perform will allow you to answer the question of “why” if auditors ever wonder what was behind any services.

“Sometimes we get so caught up in understanding the medical decision-making process for our E/M codes that the burden of documentation falls on that piece of it, whereas if we focus on the actual medical necessity part, we can hit medical decision-making with a little bit less of a burden,” said Rhonda Buckholtz, CPC, CPMA, CRC, CDEO, CHPSE, COPC, chief compliance officer of Century Vision Global, during the Aug. 7 Eye Care Leaders webinar “Understanding Medical Necessity and How It Ties Into Correct Coding.”

Here’s How They Differ

Whereas MDM is an administrative burden that comes from the E/M guidelines, medical necessity is a broader concept that demonstrates why the physician chose to perform a specific service for that patient.

“There are a lot of payer guidelines, coverage policies, and coding rules that tie around both MDM and medical necessity that if we’re not making sure we’re staying on top of the game, we’re going to see a lot of claim denials and a lot of services we can’t get approved for our patients,” Buckholtz said.

Evidence-based medicine has garnered increased attention over the past decade, she said. “It’s a platform of best evidence used to make clinical decisions on the treatment of the patient. It integrates clinical experience and patient values with research information. It’s constantly evolving with new data, technology, and outcomes.”

Insurers use evidence-based medicine to develop clinical indicators, coverage decisions, and payer policies. You’ll often see this as the criteria health plans use to authorize treatments like diagnostic testing, procedures, and more. Clinical indicators use evidence-based measures, so surgical practices are more familiar with the guidelines because when you try to get pre-approvals and meet medical policies, you give that data to the health plan to get them approved and paid.

Evidence-based medicine also gives well defined information regarding the clinical condition itself. You can’t just look at the CPT® and ICD-10 codes – you have to check the rest of the policy, Buckholtz said. “I use clinical indicators a lot when working with my doctor on documentation improvement. The clinical indicator shows the primary and secondary causes and comorbid conditions – and this is important because when I’m building my template I want to include those comorbid conditions because it tells a more accurate story of what’s going on with the patient. It includes everything going on in that physician’s brain when they’re evaluating the patient.”

If you create documentation templates at your practice, you probably include spots for the physician to record what’s been done, what’s worked, what hasn’t, etc. These slots allow the physician to document not based on coding rules, but instead on the patient’s clinical conditions. If you document this way, you’ll satisfy the medical necessity and also be able to meet the MDM required to select a code.

Check This Example

When you’re establishing your medical decision-making tally, you’ll typically review everything that the doctor has recorded, observed and performed. “Suppose we’re looking at a diabetic patient with retinal conditions,” Buckholtz said. “As a new patient, the physician’s going to review labs and history with diabetes to determine severity of the eye problem and how the patient controls or does not control the situation. Because they have to evaluate the diabetic condition in addition and it’s a new problem, and if we send them for any outside tests, that’s an additional workup. If the same patient returns for a follow up and his blood sugar results decline the provider must then look for alternative treatment options which would require more MDM than the patient who follows up and is stable and current with other treatment.”

You’ll also have to review the amount and complexity of data to select the right MDM level. “This is driven by the amount of data that has been taken into account and documented during the visit to treat the patient,” Buckholtz said. So if you have labs, radiology, and diagnostic tests from the medicine section outside that were ordered and reviewed, the provider has more information to consider when diagnosing and treating the patient. “This increases the work level in determining the MDM and if they independently review lab tests or radiology tests that we’re not also reporting the interpretation for, that takes additional work into account, so you have to look at those as well,” she added.

Understand the Table of Risk

Buckholtz often sees issues when practices tally the table of risk, which breaks down your most common risks and whether or not the risk level is moderate, severe, or self-limited. There are two commonly considered gray areas in the table of risk, Buckholtz said.

The first is surgeries with no identified risk factors vs. surgeries with identified risk factors. “All surgeries do have inherent risk factors as far as the table goes. The risk factor is based on current patient and current condition. If the surgery for this particular patient increases the risk above the normal risk for that surgery – they have a lot of comorbid conditions or complications – it will be considered WITH identified risk factors. If the risk involved in the surgery is normal risk, then it’s no additional risk factors identified.”

The second common issue is prescription drug management. “Most physicians latch onto prescription drug management and ignore the other two parts of MDM and think ‘I wrote a prescription so I can bill a level four…’ But it doesn’t work that way,” Buckholtz said. To count the prescriptions toward the moderate risk level, there must be evidence that the medication was evaluated to start, continued as prescribed, the dosage was modified, or there was a change in the medication. And then you have to review competing payer rules because sometimes they interpret that differently which can make it more difficult to manage and work through.”

What About Old Record Reviews?

Everything practitioners do during E/M services tends to count for something, and many practices wonder whether they can add points toward medical decision-making when requesting old records from other providers. “The one thing to remember for old record reviews is that it’s important the physician dates when he reviewed the record and what he found clinically relevant,” said Rhonda Buckholtz, CPC, CPMA, CRC, CDEO, CHPSE, COPC, chief compliance officer of Century Vision Global, during the Aug. 7 Eye Care Leaders webinar “Understanding Medical Necessity and How It Ties Into Correct Coding.”

“It isn’t enough to record that you imported the record – you must document what was clinically relevant that you reviewed to get those points,” Buckholtz said. “Same when you get history from someone besides the patient -- record who gave the information and the reason why.”

Focus on Thorough Documentation — The Rest Will Follow

Practices that focus on documenting for the patient’s actual clinical conditions will actually meet all of the required initiatives to justify the coding levels they performed and demonstrate medical necessity, thus allowing practices to keep ethical and accurate revenue flowing.