Ophthalmology and Optometry Coding Alert

These three elements have certain requirements to meet in order to qualify for each of the four different levels of decision-making. Many CPT manuals outline these requirements in Table 2 in the Evaluation and Management Services Guidelines. To qualify for a given level of decision-making, the physician must meet or exceed the requirements for two of the three elements, CPT states.

You can accurately assess the level of decision-making if you find a description of the patient's condition in the physician's chart, inform your physicians of necessary documentation tips, and familiarize yourself with the three elements of decision-making outlined in CPT's Table 2, titled "Complexity of Medical Decision- Making." Follow four steps for success:

1. Look for a description of the patient's condition(s) in the documentation that will indicate the status and seriousness of the diagnosis. Simple, one-word descriptors such as "stable," "worsening" or "new" may be all you need to discern how time-consuming and serious a patient's condition is, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. New or worsening conditions typically involve more time and decision- making, whereas stable conditions involve less decision- making and time on the ophthalmologist's part.

For example: Your ophthalmologist documents an established patient who presents for follow-up of diabetic retinopathy - 362.01 (Background diabetic retinopathy) or 362.02 (Proliferative diabetic retinopathy). The ophthalmologist states, based on examination or testing, that the condition is "worsening." The term "worsening" implies that the physician must review more data, consider more management options and evaluate more risk of complications.

So, using CPT's Table 2 and reviewing your physician's documentation, you may decide that the amount and/or complexity of data to be reviewed was moderate and that the risk of complications was moderate. This would lead you to determine moderate-complexity decision-making, which qualifies the visit for a level-four E/M (99214), as long as the visit meets the other required components of the visit (detailed history or detailed examination).

2. Check for a connection between the documented physical findings and the listed conditions or diagnosis. You want to make sure to count only the problems mentioned in the medical record that day.

For example: If your practice has a computerized medical record system, it may list every condition the patient has ever had in the impression area. If conjunctivitis is listed as a diagnosis, but the ophthalmologist has indicated that the conjunctiva is clear or within normal limits, then that finding isn't relevant to that day's examination and you should not count it.

3. Count rule-outs if the physician orders tests. Some people say you should not "count rule-outs in the diagnostic process of decision-making," Mac says. However, if the physician orders tests to help him rule out a particular diagnosis, that qualifies the condition as a serious consideration, and you can count it toward the number of diagnoses and management options, she says.

Remember: You cannot link the actual "rule-out" or suspected ICD-9 code to tests the physician ordered to rule out a particular diagnosis, says Pam Dickson, insurance coordinator for the Center for Sight in Huntsville, Ala. Instead, she advises, be sure to code the symptom(s) that prompted the test or, if possible, an actual diagnosis that the test reveals.

For example: A patient presents for evaluation of possible glaucoma. Upon examination, the ophthalmologist documents normal intraocular pressures (IOP) but rather large cupping of the optic discs. He performs visual field (92083) and pachymetry (76514) tests. The tests do not confirm the condition of open-angle glaucoma (365.11). Code the testing procedures and office visit linked to ICD-9 code 365.01 (Borderline glaucoma [glaucoma suspect]; open angle with borderline findings).

4. Inform physicians about proper documentation. The better the physicians document their decision-making processes, the more likely they are to get paid for the true level of service they perform. If lack of information makes selecting the appropriate level of decision-making difficult for you, ask your physicians to start providing more detailed notes. Physicians should include the definition of conditions (are they acute, chronic, recurrent, stable, worsening or exacerbated by another problem?) and the way in which these conditions influence the treatment plans, Udell says.