Ophthalmology and Optometry Coding Alert

What do I need to bill a fourth-level visit? is a question many ophthalmologists askusually in desperation, after having spent an extensive session with a new patient who is being evaluated for cataract surgery. A blend of the third- and fourth-level new patient Evaluation and Management (E/M) Service RVUs (99203 and 99204) corresponds roughly to the comprehensive eye code (92004) RVU.

Ophthalmologists really want to know what documentation is required to enable them to bill a 99204.

This scenario covers more than 70 percent of my practice, says Hemant Shaw, MD, an ophthalmologist who practices in Middletown, NJ. I see a new patient for a cataract evaluation. The patient has had poor vision in both eyes for the last four months, and cant drive at night. I do an ROS [review of systems]. She has no eye pain, no discharge, no tearing. I ask about allergies and medications. I do a complete exam of the visual system. I spend time talking with the patient about the risks, alternatives, and benefits of cataract surgery. All total, I spend about 45 minutes with the patient. I think this should be a 99204. What do I need to bill 99204? And if it were an established patient, what would I need?

We talked to two experts about how ophthalmologists should chronicle to reach a level-four E/M visit under the 1997 documentation guidelines. However, both give the same caveat: Each patient is an individual, and must be individually reviewed. When it comes to Medicare audits, anyone using a cookie-cutter approach is playing a dangerous game, and theres a strong chance that the Office of Inspector General (OIG), and not you, will win. So use their recommendations as guidance only. Dont try to make your patients fit into a higher level just because you think youve earned the money; your auditor may disagree.

Start the Exam

The exam is the easiest item to document, because ophthalmologists have been doing this for years, says Heather Freeland, a consultant with Rose and Associates, a Duncanville, TX-based consulting firm specializing in Medicare reimbursement and compliance in ophthalmology. For a new patient, you need 12 ophthalmological elements and a neurological (mental status exam) element to justify a 99204. (See box in next column for elements.)

Its important to note that the exam does not include any procedures. The eye exam only includes things that cannot be billed separately, says Freeland. For example, if you check pupils, lids, conjunctivae, cornea, iris, lens, and do tonometry, fundus photos, visual fields, and an A-scan, how many elements are there for the exam? Six. Not 10.

Fundus photos, visual fields, and the A-scans are special ophthalmological services and are not included in the exam.

Each special ophthalmological service stands on its own merit and may be coded separately from the E/M or eye exam code, says Lise Roberts, vice president of Health Care Compliance Strategies, based in Syosset, NY. Also, the pupils and iris services are both part of one bullet and count as one part of the exam instead of two.

Does a 99214 exam (established patient) need to be dilated? No, says Freeland. Because 99214 requires only an extended examination with at least nine of the bulleted elements (see below) documented. Thus, the dilated fundus (which would be required for a comprehensive exam) may not be needed if the rest of the components are performed. For a new patient, however, you do need to dilate because 99204 requires a comprehensive exam.

If the documentation is there for a comprehensive exam as indicated for E/M services, and if medical necessity exists, then the ophthalmologist not only could but should use the appropriate corresponding higher E/M code, says Roberts. The decision to perform an elective surgical procedure for a progressive condition would typically support moderate medical decision-making.

So what do you need to get to a level four? What you probably need is a patient who has something going on besides a simple cataract, says Freeland.

This may be an additional eye diagnosis such as macular edema, drusen, glaucoma, or a lid condition, says Roberts. However, she adds, it may also be a systemic condition which must be considered when contemplating surgery. Such conditions might include diabetes, hypertension, or heart conditions. It is the systemic conditions that make the history-taking especially important in capturing a fourth-level E/M code, Roberts notes.

Ophthalmological Elements: Test visual acuity (does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility, including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexa, including lids (e.g., ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises, including shape, direct and consensual reaction (afferent pupil), size e.g., anisocoria) and morphology Slit lamp examination of the corneas, including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers, including depth, cells, and flare Slit lamp examination of the lenses, including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) Opthalmoscopic examination through dilated pupils (unless contraindicated) of: Optic discs, including size, C/D ratio, appearance (e.g., atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments, including retina and vessels (e.g., exudates and hemorrhages) Neurological Elements: Brief assessment of mental status, including: Orientation to time, place and person Mood and affect (e.g., depression, anxiety, agitation) (Source: HCFA)

Comprehensive History

History consists of four parts: the chief complaint (CC), the history of the present illness (HPI), the review of systems (ROS), and the past, family, and/or social history (PFSH).

A comprehensive history is required for a level-four visit for a new patient. Many ophthalmogists perform this level of service, but fail to document it properly to meet the criteria, Freeland says. You have to do the documentation in order to bill a level four, she admonishes.

1. Review of Systems (ROS)

A. New patients. The ROS for new patients for a level-four visit requires that 10 systems be reviewed. Both positive and negative patient answers must be documented to get credit (in an audit) for asking the questions. There is also a provision in the documentation guidelines that indicates another way to achieve a complete ROS, says Roberts. If the physician documents responses to questions about the system of complaint (e.g. ocular), asks the patient if he or she is experiencing any other symptoms anywhere in his or her body, and documents the response to that question; then the ophthalmologist may indicate all other systems are negative, says Roberts. This form of documentation also meets the criteria for a complete ROS.

Below are the systems recognized by the AMA and HCFA, which can make up your comprehensive history documentation:

Constitutional symptoms (e.g., fever, weight loss)
Eyes (doesnt count in ophthalmology)
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

B. Established patients. For an established-patient level-four visit, you need at least two of the above systems to be reviewed, and you can update the ROS you have in the file, says Freeland. This makes the ROS easier for a 99214 than a 99204. HCFA says an update to an existing history qualifies for a ROS, she states. In ophthalmology, the most commonly updated systems for an established patient are allergy and cardiovascular, says Freeland.

If you update a previously captured comprehensive history, you must indicate in the current progress note the date of the referenced history, says Roberts. You will only get credit for a previously captured ROS and PFSH, however, she adds. You must still document a CC and HPI for the current visit. If there have been changes since the previously captured history was recorded, they must be indicated either on the current progress note or as addenda to the previous history, signed and dated by the physician, Roberts explains. If changes are documented in the current progress note, a statement such as changes since (date of previous history) as follows: _______ should be documented. If changes are documented such as ROS and PFSH: See updated history form dated [date of previously captured history] should be entered in the current progress note.

2. Past, Family, and/or Social History (PFSH)

A. New patients. For the PFSH, you need one of each (past, family, and social history) to qualify for a level-four visit for a new patient, explains Freeland. This means you can ask one question about each; as with the ROS, the answer can be either negative or positive. For example, for the social history, you might ask about marital status. Its important for the ophthalmologist to know the home environment, Freeland notes. If the patient lives alone, how will he or she get home after surgery?

Tip: If the ophthalmologist discovers macular degeneration, the physician will also want to know if the patient smokes; this is a social question, she adds.

If you can document at least one pertinent item for each of the threepast, family, and social historythen you will have satisfied that part of the exam for a level-four visit for a new patient, says Freeland.

B. Established patients. For an established patient, you only need a pertinent PFSH to qualify for 99214. This means you only need to review and update one: either the past, the family, or the social history. For example, perhaps the patient has been diagnosed with diabetes, or had the gallbladder removed, since your last encounter. This would update the past history. So would a brother having been diagnosed with cancer. This would update the family history. Death of the patients spouse would update the social history. As long as you ask the question, and the patient says there have been no changes, and you notate it in the record as described above, you have fulfilled the requirements for a 99214. The PFSH is pretty easy to get for an established patient, even for a level-four visit, notes Freeland.

3. Chief Complaint (CC)

The CC can be a problem in the cataract evaluation scenarionot because of any inherent difficulty with the documentation but because the correct question isnt asked. What is sometimes overlooked by a cataract practice is the documentation of the present illness and the chief complaint, says Freeland. The chief complaint is the reason the patient is there. It is closely intermingled with the HPI.

You cannot simply say cataract check, notes Freeland. You can have a beautiful PFSH, but if all that is indicated under chief complaint is cataract check, all that hard work is for nothing. That kind of CC would drop the visit down to a level two. This is where your technician can really help you, Freeland notes. The technician needs to ask: What is going on? How is your vision affecting your lifestyle?

WARNING: The whole cataract surgery can be determined to be medically unnecessary by Medicare if there is not a patient complaint of lifestyle limitations due to the decreased vision attributable to the cataract, Roberts cautions. The patient complaint must be documented in the progress note in which the determination to do the surgery was made.

4. History of Present Illness (HPI)

An extended HPI, which is what you need for a level-four visit, consists of at least four elements of the HPI. The elements include the following:

location quality severity duration
timing context modifying factors
associated signs and symptoms

For example, lets say a patient says, I have difficulty driving. To justify an extended HPI, the technician needs to probe a little farther. Does the patient have difficulty driving at night? Difficulty reading road signs? Does the glare of headlights at night create problems? A really clarifying statement to put in the medical record is that the patient has difficulty driving at night due to glare of the headlights, and has had this difficulty for the past year. This includes location (eye), quality (difficulty driving), timing (at night), duration (past year), and context (glare). This amounts to five elements, which exceeds the minimum required for an HPI. If the patient says the problem is difficulty reading, the technician should ask, Difficulty reading what, under what conditions? suggests Freeland. The point is to be as specific as possible and to document all of your findings; then the HPI elements will fall into place.

Medical Decision-Making

The trickiest part of documentation is medical decision-making. Its the only part that hasnt been quantified, notes Freeland. This should be somewhat reassuring: It means that physicians can use their judgement, that medicine really is an art and a science, that documentation of medical problems isnt just counting bullets. But it also means that the fourth level can disappear as an option at the medical decision-making stage if you recognize that your decision-making is simple and straightforward.

A level-four visit for a new or established patient requires a moderate to high level of complexity of medical decision-making. What does this mean? For one thing, it means moderate to high risk of complications or mortality, says Freeland. And for another, it means there are either a number of management options and diagnoses, or that the diagnoses or management options represent moderate- to high-risk issues in decision-making.

Although the decision to perform cataract surgery may seem fairly straightforward to a well-trained ophthalmologist, it is, in fact, a significant decision-making process which is derived fairly quickly because of the physicians level of training, not because the decision is self-evident, says Roberts. It is a decision to perform an elective surgery, which has inherent risks as an invasive procedure, she says. When CPTs Complexity of Medical Decision Making table is reviewed, adds Roberts, one can see that under management options, the decision to perform an elective major surgical procedure is considered moderately complex.

Does cataract surgery ever have high risk? It could, says Freeland. Any surgery carries some risk, of course, and cataract surgery, because it is completely elective, is normally moderate on the risk scale associated with the moderate complexity decision-making required for both 99204 and 99214.

If the patient has a specific risk factor that places him or her at higher risk of complication than the normal patient population, that fact bumps up the contemplated surgery to high risk, says Roberts. For example, the patient may be an uncontrolled diabetic or highly myopic, each of which places the patient at higher risk than the normal population for retinal detachment, Roberts says.

But the most important part of medical decision-making for qualifying for a level-four visit is the number of management options and diagnoses, says Freeland. Its interesting that HCFA says, number of, but doesnt set a number, the consultant notes. So five little options to be considered count more than one big one.

The management options must be medical conditions that the ophthalmologist seriously considered during the exam, after reviewing the history, says Freeland. Lets say the history of the cataract patient shows a family background of diabetes and hypertension. You ask the patient if she has hypertension. She says, yes, shes on medication. Right away, you have a management option when it comes to the surgery.

HCFAs Point System

So the question is, how many management options and diagnoses do you need to qualify for a level-four visit, under medical decision-making? HCFA doesnt spell it out in the documentation guidelines, but does have a point system developed for their auditors to use, Roberts explains. The variables that determine how many points you are credited with are:

number of new or established self-limited or minor problems (1 point each with a maximum of 2 points possible)

number of established, stable, or improved problems (1 point each)

number of established, worsening problems (2 points each)

number of new conditions not requiring additional work-up (3 points regardless of now many new conditions)
number of new conditions requiring additional work-up (4 points each)

The auditor is instructed that one point is minimal, two points are limited, three points are multiple, and four points are extensive. It is multiple that corresponds to the number of diagnoses and/or management options requirement for moderate medical decision-making, indicated for both 99204 and 99214, says Roberts.

You could have one diagnosis and one management option and still qualify for a level four, Roberts explains. It would have to be a progressive diagnosis, and one which would warrant having surgery. For example, the patient could have a new diagnosis of angle closure glaucoma, an attack of angle closure, says Roberts. The patient has extremely high intraocular pressure. You undertake to medically manage it first, but this doesnt work. So you take the patient to the OR. This is high-complexity medical decision-making, Roberts explains.