Ophthalmology and Optometry Coding Alert

When an ophthalmologist documents a follow-up visit for a chronic condition, he or she should not use the word routine. Medicare does not pay for services labeled routine because the word suggests something that is not medically necessary.

If a chronic condition is the reason for the visit, document the condition as the first entry in the chart, even if the patient says he or she feels fine and sees without a problem. After that entry, record any relevant history of the present illness and any new signs and symptoms.

For example, a patient comes for a six-month follow- up of age-related macular degeneration and reports no complaints or changes in visual acuity. According to Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding and compliance consultancy, the note should look similar to: Pt here for 6 mo f/u ARMD, no complaints, VA stable. Note the absence of the word routine.

When to Use Yearly

Avoid yearly and annual as well, recommends Heather Loveland, CPC, president of Physicians Advantage, a Hendersonville, Tenn.-based consultancy that bills for ophthalmologists and optometrists. We reserve the term yearly for routine, yearly eye health examinations, Loveland says. We use the phrase follow- up for any exam performed as a result of a continuing problem or management of a medical problem. For example, three- or four-month visits for chronic problems such as glaucoma are termed follow-ups.

Other examples include a follow-up visit on slow progressing cataracts or on age-related macular degeneration that occurs yearly or every six months.

But sometimes, yearly and medical necessity are not in conflict. Sherry Searson, CPC, an independent coding consultant specializing in ophthalmology based in Ravenel, S.C., uses the word yearly, but says that as long as the chief complaint substantiates medical necessity as in yearly cataract evaluation, it isnt a problem. For example, perhaps the patient has nuclear sclerotic cataracts, but vision is not bad enough for surgery. The patient needs to return a year later for another exam. Use the type of cataracts the patient has as the primary diagnosis. This points out that the context in which terms are documented sometimes makes the difference. Documenting yearly exam could get the service denied in an audit, whereas yearly cataract evaluation would not. In either case, you would probably use the same code: 92012.

Use Chronic Condition as Diagnosis Code

Some coders think they should use the chief complaint as the primary diagnosis. If there is no complaint in other words, if the patient feels fine but is having a six-month, age-related macular degeneration follow-up leaving out the macular degeneration diagnosis would make the visit nonreimbursable. And Medicare and most other payers cover follow-ups for such chronic conditions.

When to List the Chronic Condition Code First

Medicare only requires (1) that the reason for the exam be related to the primary diagnosis, and (2) that the reason for the exam establish that a reasonable and necessary service needed to take place, explains Lise Roberts, vice president of Health Care Compliance Strategies, a company based in Jericho, N.Y. that develops interactive compliance training courses.

If the patient presents with new symptoms at a follow-up, and a definitive diagnosis determined by the end of the examination explains those symptoms, you can code that definitive diagnosis as the primary diagnosis, Roberts says. If there is no definitive diagnosis at the end of the exam, the symptom(s) should be coded as primary if they were the reason for the exam, she says. If the reason for the exam was a chronic condition, that code should be listed first, and then any new symptoms for which there is no definitive diagnosis yet would be listed.