Ophthalmology and Optometry Coding Alert

The Health Care Financing Administration (HCFA) says you can use either the 1995 or the 1997 documentation guidelines for Evaluation and Management (E/M) services, but you must use one or the other, and you must use it consistently. The 1997 guidelines were originally scheduled for publication in CPT 1999, but instead the 1995 version still appears. However, this is only while HCFA is working on a revised set of new guidelines, expected out in late 1999 or early 2000.

Simpler Documentation

Two ophthalmological coding experts were consulted for this article, both of whom recommend the use of the 1997 guidelines. A lot of ophthalmologists would rather use the 1995 version, because they appear to require less documentation, says Ann Rose, president of Rose and Associates, a Duncanville, TX-based consulting firm specializing in Medicare reimbursement and compliance in ophthalmology. But for ophthalmology, the 1995 guidelines are not simpler. Using the 1995 edition leaves the determination of the level of service to the discretion of the individual carriers medical reviewer, says Rose. While the 1997 edition defines exactly what constitutes a certain level of service for the examination component of an E/M service.

The 1995 E/M codes were written for the general doctor, not the specialist, she explains. Until 1992, Rose adds, ophthalmologists and optometrists had their own set of codes in addition to the medical visit 90 series of codes. All other physicians used the 90 series. The 99 series (as in 99212) of E/M codes replaced the 90 series in 1992, and were developed for use by all specialties. The single organ system documentation guidelines were developed for 10 specialties, including ophthalmology, in May of 1997.

The documentation guidelines for each level are:

Problem-focused exam (99201 or 99212) you need to have one to five elements;

Expanded problem focused exam (99202 or 99213), you need at least six elements;

Detailed exam (99203 or 99214), you need at least nine elements;

Comprehensive exam (99204, 99205, or 99215) you need to perform all of the above elements, and also provide a brief assessment of the patients mental status, either by orientation to time, place, and person; or by mood and affect (e.g., depression, anxiety, agitation).

(Reminder: The examination alone doesnt determine the level of service; you must also meet certain criteria for history and medical decision-making. For a comprehensive level of E/M service, the history must contain the chief complaint, the history of the present illness, a complete review of systems, and a complete past, family, and social history (PFSH). Under the 1997 guidelines, a brief history of the present illness (one to three elements of the illness) would only qualify for a level 2 or 3 E/M service; a level 4 or 5 would require an extended history of the present illness (at least four elements of the illness, or the status of at least three chronic conditions). No review of systems is required for a level 2 E/M service for an established patient; a problem-pertinent ROS is used for a level 3 E/M service provided to an established patient, an extended ROS (two to nine body systems) for a level 4 E/M service provided to an established patient, and a complete ROS (at least 10 organ systems) for a level 5 E/M service provided to an established patient. The PFSH is not necessary for a level 2 or 3 E/M service for an established patient; for a level 4 E/M service for an established patient, the PFSH must be pertinent (at least one entry for either past, family, or social history); and for a level 5 E/M service for an established patient, it must be complete (at least one entry for two of past, family, and social history for an established patient). Medical decision-making consists of the number of possible diagnoses and management options, the amount and/or complexity of data to be reviewed, and the risk of significant complications, morbidity, and/or mortality.)

Okay, so this might not sound simple. But if you realize its just a matter of documenting the work you are doing anyway, its more logical and youre not at the mercy of the carriers auditor. And if you are ever audited, this documentation will be your best defense, because you will have followed the rules -- rules which are clearly spelled out in the 1997 guidelines.

1997 Eye Examination Documentation Requirements 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) Ophthalmoscopic 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)

1995 Version Audits

With the 1995 documentation guidelines, you must select a level of service based on history, examination, and decision-making but there is more art and less science involved in the selection. This makes documentation more difficult, according to Ramona Cosme, president of Ramco Medical Billing, an Edison, NJ-based billing firm specializing in ophthalmology. 1995 is generic, 1997 is specific, she states. When I go into a practice, the first thing I ask is, What are you basing your levels of service on? Cosme explains. This is exactly what an auditor will want to know, and Cosmes job is to help her clients steer clear of an audit (or, if its a random audit, to pass). With the 1997 guidelines, you know exactly what criteria you need, because of those exam bullets, Cosme says. The ophthalmologist can just check off bullets, and the coder can add them up, Rose relates.

Use a Template

The check-off sheet is commonly used in ophthalmology practices, but the consultant warns that unless the sheet is filled out properly, it will not pass a carrier audit. Medicare doesnt mind check-off sheets, she adds. But nine times out of ten the doctor will put a line through all the boxes and say normal, she adds. This is not adequate documentation. Each item must be checked yes or no, so that Medicare knows each element was examined, explains Rose.

So while a check-off sheet or template is appealing, dont think that having one will make documentation simple, she relates. This chart sheet can easily be three or four pages long in ophthalmology, for a new patient. You need the chief complaint, and then you may need the notes for a refractive test, a visual acuity exam, a sensorimotor exam, a slit-lamp exam, and then, if you do an extended ophthalmoscopy, youll need drawings, Rose maintains.

Another reason we recommend the 1997 guidelines is that theyre performing the listed elements already as part of the general ophthalmic examination, says Rose. The 1997 documentation requirements for eye examinations are very similar to the ophthalmic exam codes (92002, 92004, 92012, and 92014).

Do you need to follow those bulleted elements for the exam if you are using the eye exam codes? It depends on your Medicare carrier. You should check your carrier newsletters to see if they have published a policy on the intermediate [92002, 92012] and comprehensive codes [92004, 92014], she recommends.

Important Tip: Check with your carrier to see what the criteria for eye exams are.

One benefit of using the eye exam codes over the E/M codes is that you dont have to document history and medical decision-making. However, this is true of both sets of E/M guidelines 1995 and 1997.

Be Prepared if Pool of Elements Comes

The final reason to use the 1997 guidelines is to help you be prepared for what the documentation guidelines may look like when they finally come out. It is quite possible that instead of single organ system examinations, there will be a pool of elements for the examination component, to be utilized by all specialties, says Rose. Out of 100 or more elements in the pool there are at least 26 elements that the ophthalmologist might have to document, she explains. Some elements, including things like checking vital signs or the condition of the skin or the face, would be needed for a comprehensive examination. Using the 1997 guidelines now, Rose concludes, will prepare the ophthalmologist for the transition to the new guidelines once they are published.