Ophthalmology and Optometry Coding Alert

If you think each patient’s medical chart simply consists of an office note for one single individual encounter, think again.

That was one key piece advice from Kathy Boehm, senior provider relations representative with Palmetto GBA, during the Part B payer’s May 20 webinar, “Part B: Medicare Follows the Money.”

In fact, she said, a patient’s medical chart encompasses a wide variety of items. And in every situation, the documentation is going to be used to form the basis for the codes that are submitted on the claim. The medical documentation actually includes all the following, Boehm said:

• Justification of who provided the service
• Information about when and where the service was provided
• An explanation of what service occurred, and the extent of the service that was provided
• The indication of why the service was provided
• Information about which tests were ordered and why
• A description of the plan of care

“Providers need to maintain — and submit, when requested — adequate documentation to ensure that claims are supported as billed,” Boehm said. “The medical chart is a complete record of a patient’s key clinical data and medical history, such as their demographics, vital signs, diagnosis, medications, treatment plan, progress notes, problems, immunization date, allergies, radiology, images, and laboratory test results,” she noted.

Check out these myths to ensure that you aren’t falling prey to some of the common misconceptions about medical record documentation.

Myth 1: When Billing Based on Time, Documentation of Time Is Enough

“If time is a factor in selection of an office or outpatient evaluation and management service, documentation should include the start and stop time or total time,” Boehm said. However, you can’t stop there. You must still justify medical necessity before you can report any particular code.

“Remember, the record needs to address the question of why the services were rendered for your individual patients,” she said. “This addresses the medical necessity of each service. Some services have policies that define when a service will be considered medically necessary under Medicare coverage guidelines.”

Myth 2: Your Diagnosis Code Alone Can Justify Medical Necessity

Just as it isn’t enough to document the time you spend when you’re trying to justify medical necessity, you also can’t meet that goal by simply assigning a particular diagnosis code to a claim. Some coders will see a specific ICD-10-CM code listed on a local coverage determination (LCD) and assume that as long as their patient’s diagnosis code matches that, then the claim will sail through the approval process — but that isn’t accurate, Boehm said.

“A diagnosis code by itself on a claim does not alone support medical necessity, and documentation for each patient’s encounter must be maintained to support medical necessity,” she noted. “Medical necessity of a service is the overarching criterion for payments in addition to the individual requirements of the CPT® or HCPCS code that’s being billed.”

Myth 3: It’s Against HIPAA Rules to Give Patient Records to Medicare Reps

When medical review contractors from Part B MACs contact medical practices to request records so they can confirm the medical necessity of services rendered, practices can’t use HIPAA privacy laws as an excuse to withhold records, Boehm said.

“Some providers often tell us that they are not able to provide medical records to the CMS review entity because they believe it is a HIPAA violation,” Boehm said. “As a reminder, it is not a HIPAA violation to provide documentation to support a Medicare claim. Remember, your patient authorizes you to submit a Medicare claim, and therefore should be aware that you may need to provide documentation to support the services that you billed and receive patient reimbursement for.”

Myth 4: You Can Document All Your Services When You Get Around to It

Some providers believe they don’t have time to document the medical record during or right after the encounter and may wait until later to fill out their charts. But that’s not a good habit, Boehm said.

“Health care providers are busy, and we understand that, but it’s important to maintain an accurate medical record,” she noted. “This means documenting services during the encounter, or as soon as is practical after the encounter. Don’t let that time slip away, along with the details of the encounter or service. Only the pieces and parts of a specific service may get documented if too much time has passed and the provider can’t remember all of the details — details that may be the difference between identifying a correctly documented service, and one that doesn’t support the service billed. I don’t think any practice wants to defend the provider’s memory, so we encourage providers to stay on top of that documentation.”

Myth 5: Conflicting Information Submitted by Providers Isn’t a Big Deal

Not every service can be performed at your office, and some services must be ordered or referred. For instance, if you suspect that a patient has a fractured orbit, you’re likely to order an X-ray that’s performed and interpreted by another physician. This makes you the ordering provider of that X-ray. Or, in some cases, you are asked by another physician to examine a patient and provide your opinion based on the request of another doctor. In this situation, you are the rendering physician. So whether your eye care specialist is the physician performing the service or the one ordering it from someone else, both parties need to maintain medical records.

In cases when a MAC requests the medical records of a particular service, the payer will need the records from both the ordering and the rendering providers to confirm medical necessity. “If a response is received from one or both that failed to support the medical necessity of the service, that claim will be denied in full or in part,” Boehm said. “When documentation is submitted by both the performing and the ordering provider, and that documentation conflicts, the service may be denied.”