Ophthalmology and Optometry Coding Alert

Ron Evans, controller for Don W. Barham, MD of Dothan, AL, writes to ask if Medicare will pay if the patient has a specific complaint, but the physician cant find anything wrong after his or her exam. For example, the patient complains of a foreign body sensation, but no foreign body is found, says Evans.

The short answer to Evans question is yes. A complaint is enough to justify the claim, says Terry Fletcher, CPC, CCS, a health care coding consultant specializing in ophthalmology. Because you have a sign, symptom, or indication, it shows medical necessity, says Fletcher, who is also a coding seminar leader in ophthalmology for McVey Associates, a national coding seminar company.

The rationale here is simple: As long as there is a chief complaint, and you have documented it, you have fulfilled your requirement for this part of the examination, Fletcher explains.

When billing Medicare, you need to keep it simple and be as specific as possible with diagnosis codes.

Code for Symptom if No Diagnosis Present

A lot of physicians feel pressed to provide a definitive diagnosis, even though the symptom is the only thing they can find, states Fletcher. Ophthalmologists need to help their coding staff by being as clear as possible in their chart notes. If the symptom is the only thing the patient has, then the physician shouldnt attempt to put in a further diagnosis just for the sake of having one in the record.

This means that when a patient comes in complaining of eye pain, this symptom is what you indicate as a diagnosis (379.91, pain in or around eye). This is probably what a foreign-body sensation would be coded as. Yes, this code is an unspecific code -- defined under unspecified disorder of eye and adnexa but its not as bad as using 379.99 (other ill-defined disorders of eye), which is too vague in many instances. You should not code a probable, suspected, or possible diagnosis; instead, use symptom codes.

Medicare will consider any symptomatic ICD-9 code except a V72.0 (routine eye exam), says Nina DeMasi, administrator of Ophthalmic Associates, a three-physician practice in Trumbull, CT. For example, sometimes a patient might come in and say they are having trouble reading the newspaper. Medicare will consider blurry vision (368.8), because that is a complaint. Its really a symptom, not a disease, but the code is appropriate to the complaint -- and it will usually be reimbursed.

Identifying Specific Diagnosis Codes

In addition to simplicity, its good to be as specific as possible. DeMasi concedes that it does take a little bit of work to arrive at the most specific diagnosis code, but in the end, its worth it. There could be something in the eye that made it inflamed, she says, and then you would use a diagnosis code such as corneal abrasion (918.1) or conjunctival abrasion (918.2).

If there is a foreign body in the eye, the chances are there is some kind of pain, says DeMasi. A patient could have dry eye (375.15) which is causing an irritation, she explains. The irritation could be caused by an eyelash (and then the physician might perform an epilation -- 67820). You have to get the patient to be as specific as possible, stresses DeMasi. This will increase your chances of reimbursement, she adds.

The longer answer to Evans earlier question applies to non-Medicare patients, for whom listing the complaint as a diagnosis may not be enough to be reimbursed.

Commercial Insurers Need Specific Diagnosis

If you are dealing with a commercial HMO, you really need to pay special attention to the specificity of your diagnoses, says DeMasi. As a general rule, commercial HMOs do not accept complaints [on their claims], she says. They want specific diagnoses.

(Tip: HMOs that require a referral from a primary care provider expect that the ophthalmologist will report a diagnosis, not a symptom.)

However, HMOs do pay for a non-Medicare patient who comes in with no complaint but whom the ophthalmologist discovers does have a pathological condition.

Billing for Routine Checks

What should you do if a patient comes to your ophthalmology practice for an eye examination and has no specific complaint? If he just wants his eyes checked, and thats all he says he wants, then Medicare wont cover it, says DeMasi. If the patient just wants his eyes checked, and the physician then discovers glaucoma, which is a silent disease so the patient wouldnt know to complain about it, Medicare still will not cover the visit.

(Tip: But if you probe a little further, there usually is something that is bothering the patient, DeMasi tells us. Stick to diagnosis codes that represent the patients complaint, with appropriate documentation, and you will be reimbursed for that visit.)