Ophthalmology and Optometry Coding Alert

Do you know what’s necessary for cataract, blepharoplasty best practices?

Although coding clarity is often the key to collecting reimbursement, your documentation is what will ensure that you’re able to keep the money you collect for your services.

To help you visualize exactly what’s necessary to have in your records, we’re breaking down some of the best practices for documenting common eye care procedures. These tips should help you maintain thorough, clear notes that support all of your codes.

Know the Ideal Cataract Documentation

When you perform cataract excisions, the patient’s medical record must include specific documentation that justifies the medical necessity for the procedure. This can vary based on the patient’s exact situation, and you must consult your payers’ guidelines for the specifics. However, in the case of a visually symptomatic cataract, Medicare guidelines indicate that the record should contain:

• A statement that describes specific symptomatic impairment of visual function resulting in specific activity limitations.
• The patient’s own words describing their condition. For instance, “My right eye is so foggy I can’t even read street signs, but my left eye is clear.” This type of patient-specific comment shows the individuality of each patient record.
• A statement or measurement showing that the patient’s visual impairment is not correctable with a tolerable change in glasses or contacts. Past exam findings included here would be helpful if the deficit has changed.
• A best-corrected Snellen visual acuity at distance under standard testing conditions. Whereas neither uncorrected nor corrected visual acuity with the patient’s current prescription will satisfy this requirement, the refraction must be performed by the surgeon or suitably trained staff members. When cataract is the primary cause of impairment, the degree of lens opacity should correlate with the impairment.
• If there are coexisting ocular diseases, the medical record should indicate that the cataract is the primary cause of visual compromise.
• A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained, and that a reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient. Again, this makes the documentation patient-specific and shows how the condition affects them personally.

Based on documentation of these details, you can better support the codes you report for treating these cataracts.

Blepharoplasty Documentation Must Demonstrate Noncosmetic Nature

Medicare payers have long kept blepharoplasty claims on their list of services under review. That’s because this procedure (15823, Blepharoplasty, upper eyelid; with excessive skin weighting down lid) can be reported not only for medically necessary procedures, but also for cosmetic reasons. Although medically necessary blepharoplasty services are reimbursable, cosmetic procedures are statutorily excluded from Medicare payments.

Medicare contractors that have reviewed blepharoplasty claims in the past have found that the most common error was insufficient documentation, which included the following issues:

• Missing authenticated or signed visual field testing
• No pre-surgical photographs that were signed or authenticated and interpreted
• Missing op notes
• No documentation of the medical necessity of the procedure
• Missing physician’s signature on the notes

If you fail to have any of these items in your files for blepharoplasty, the payer could deny payment, or request reimbursement back if you’ve already collected for the procedure.

Many insurers, including most Medicare contractors, require you to take photographs documenting the excess skin over the patient’s eyes. WPS Medicare’s policy, for example, says the following: “Photographs and medical record documentation must demonstrate at least one of the following (Digital or film photographs are acceptable) - For Blepharoplasty Repair: Frontal photos are needed to demonstrate redundant skin on the upper eyelids:

1. Upper eyelid skin resting on the eyelashes or over eyelid margin
2. Upper eyelid dermatitis secondary to redundant skin
3. Dermatochalasis

You’ll want to retain any required photographs in the patient’s file, says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York.

Other payers may have even more specific requirements for your photographs. Noridian Medicare, for example, says you must have high-quality detailed photographs showing the “redundant eyelid tissue hanging over the eyelid margin resulting in pseudoptosis where the ‘pseudo’ margin produces a central ‘pseudo-MRD’ of 2.0 mm or less, or redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze.”

In addition, Noridian wants to see images where the patient’s head is in a parallel plane to the camera rather than being tilted. “Unless medial/lateral gaze is required to demonstrate a specific deficit, photos should be with gaze in the primary position, looking straight ahead,” Noridian notes. “Oblique photos are only necessary if needed to better demonstrate a finding not clearly shown by other requested photos.”

Always Demonstrate Why You Performed Retinal Photocoagulation

Retinal photocoagulation services can be lucrative for eye care offices, paying around $320 per service. However, that high price tag comes with scrutiny, and CMS has launched multiple audits of code 67228 (Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation). During prior reviews, it was discovered that most improper payments for this service were due to insufficient documentation, leading payers to request money back for what practices had collected for these procedures.

To ensure that you aren’t forced to send back reimbursement to your carrier, ensure that all progress notes are complete. When the physician sees the patient for their initial appointment, the doctor can’t skimp on a full description of what they saw — otherwise, you might lack documentation of medical necessity for the procedure itself. Ensure that the record is clear about why the service was necessary, along with notes about previous visits, signs, symptoms, and firm diagnoses.

If you aren’t sure whether your notes for 67228 are up to snuff, consider the following sample note for a retinal photocoagulation treatment:

“Mrs. Jones presents for retinal photocoagulation today due to OS diabetic retinopathy. Patient was appropriately prepped and anesthetized. I measured her visual acuity and dilated the patient’s pupil. Using a slit lamp delivery system after applying a fundus contact lens to the globe, ablated to the mid-peripheral and peripheral retina via laser. After confirming that the target vessels were appropriately coagulated and necrotized, the patient was advised of appropriate post-procedure ophthalmic care and asked to return in three days.”