Ophthalmology and Optometry Coding Alert

In the wake of Medicare's Comprehensive Error Rate Testing (CERT) report in which new patient, outpatient, and subsequent hospital care codes dominated a list of errors, your office should be scrambling to polish its E/M claims.

If an ophthalmologist is requested to see a patient in the hospital for an evaluation of an ophthalmic problem, a consultation may be performed and the patient could warrant the need for follow-up hospital visits during the course of the patient's hospital stay. Understanding the level of the key components needed for the history, exam, and medical decision making is essential when selecting the E/M code.

Take a closer look at CERT's three worst offenders, and see how you can defend your use of these codes to Medicare and private payers.

New patient office visits (99201-99205) have a 15.5 percent error tally, according to the last Improper Medicare Fee-For-Service Payments Report -- May 2008 Report. "The biggest issue is that the physicians usually do the work, but do not document it correctly," says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education LLC. In your next physician education meeting, point out the differences between 99201-99205 and 99212-99215. "New patient office visit levels have different key component requirements than the established patient levels," Vogelberger says. When choosing a new patient office visit level, you need all three key components to determine the level of service. Often, physicians overlook the "three of three" requirement.

"They tend to score lower in one of the key components and that pulls the code down," Vogelberger says.

The level you report must match the level of the patient's problem. For instance, you shouldn't bill a level five for the sniffles, Vogelberger says. The history and examination workup may be at a level five, but if it wasn't medically necessary, insurers may consider the charge overcoded and request a payback. "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code," states the Medicare Claims Processing Manual, Chapter 12. Overcoding resulted in overpayments of $242 million on 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family).

Caution your ophthalmologists to consider the problem and count only medically necessary elements.

Be Sure There's Documentation for 99232

The CMS report also indicates that Medicare paid out nearly $39 million more than it should have for subsequent hospital care code 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit) in the "insufficient documentation" error category (See www.cms.hhs.gov/cert for more information.).

"It's possible that doctors in the hospital tend to peek in on the patient and don't write a lot in the chart," notes Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network and president of CRN Healthcare Solutions in Tinton Falls, N.J.

"The physician may write, 'Patient stable,' or 'Patient a bit worse, order xyz tests,' and although he may have examined the patient, he may not document all his work" to support a level-two hospital visit, Cobuzzi adds. Therefore, what Medicare reviewers may classify as "upcoding" may simply be your physician underdocumenting the medical record.