Ophthalmology and Optometry Coding Alert

There was a time when an ophthalmology practice would get paid for cataract surgery, no questions asked. Now some commercial insurance companies are requiring extensive documentation before granting precertification for such procedures. And Medicare carriers want to make sure there is medical necessity for these procedures as well.

There are two or three main criteria that payers look at for medical necessity: the history, a vision test, and, sometimes, a glare test. But the most important is history.

Why History is Key

The technician or physician must ask every patient whether there are any visual problems interfering with their lifestyle, explains Theresa Collins, insurance supervisor for Suncoast Eye Center in Hudson, FL.

Basic questions should cover whether there is any difficulty with reading, driving, driving at night, seeing something far away, seeing something close up, doing fine tasks such as threading a needle, and more, says Collins. The answers to these questions can substantiate medical necessity for cataract surgery, so its important for the technician to do a thorough interview. The patient must have a complaint that the vision problem is impairing his or her daily living activities in some way regardless of how bad the best corrected visual acuity is.

A history questionnaire may sound easy, but this isnt as straightforward as you think. (For an example of a patient questionnaire, please see box on page 74.) There are subtle psychological influences at work here. A lot of patients dont want to admit that theyre having a problem seeing, notes Jane Walls, surgery scheduler for the North Iowa Eye Clinic in Mason City, IA. Many patients are retired, and they really dont want to say they are having problems driving. They need to get from point A to point Bits their life. Some patients have even stopped driving because they know they cant see well enough, but they still want to keep their license, and for that reasonas well as for vanity reasonswill not confess to having problems. This takes some sensitivity on the part of the technician.

Sometimes you have to reword the question, says Walls. You dont want to sound too threatening. One way is to tell them that youre not going to report them to the Department of Transportation.

Another important message to get across is that the problemwhatever it is doesnt have to be suffered in silence. There can be a treatmentsuch as cataract surgery if the problem is a cataract. You can explain its okay to have this problem, because it can be fixed, Walls adds.

What really brings many of these reluctant patients in is failing the vision part of the drivers license renewal test, she continues. In many cases, the cataract has gotten quite dense or discolored. But both the patient and the patients family value the independence that comes with driving, and immediately upon failure of the drivers test, schedule an appointment with the ophthalmologist. It would be better from a clinical viewpoint, as well as the viewpoint of the patient, to assess a cataract earlier and to review options with the patient.

This thorough interview not only will make it easier for the physician to know what steps to take next, but it will also form the basis of medical necessity. If an ophthalmologists patient is having trouble seeing, working, reading or driving, for example, there is a medical necessity for whatever treatment will correct it (unless, of course, the problem is a refractive one that can be corrected by a change in glasses or contact lenses), and thus most carriers including Medicare will cover the treatment.

And payersespecially commercial insurance companiesreally do want to see the notes on these interviews. I have had precerts denied for cataract surgery, explains Collins. Payment is not automatic any more. When this happens, she has to send all of the records, including interview notes, to prove medical necessity. And an increasing number of commercial insurance companies are demanding a records review before precertifying cataract surgery anyway. These private carriers have a nurse review the record, says Collins. It usually takes three to five days. So be prepared and have a good record of these interviews. Be sure to elicit information about vision and lifestyle, and be sure to document your findings.

Sample Patient Questionnaire When interviewing a patient about vision problems, most ophthalmological practices have a list of questions they run through, which includes rephrasing similar questions to help with the psychological aspect of the question. These questions include the following: 1. Do you have a problem reading newspapers? 2. Can you read traffic signs? 3. Do you have trouble recognizing people? 4. Can you see cracks in the sidewalk? 5. Do you have trouble watching TV? 6. Do sight problems give you trouble working at your job? 7. Have you been bothered by poor night vision? 8. Do you see rings around lights? 9. Do you have trouble seeing in poor or dim light? 10. Do you have trouble with glare? 11. Do you have hazy vision? 12. Do you have blurry vision? 13. Are you able to drive during the day? 14. Are you able to drive at night? 15. Do problems with your vision make you afraid to drive during the day? 16. Do problems with your vision make you afraid to drive at night? 17. During the past six months, have you made any driving errors? 18. How is your vision with your glasses or contacts now? 19. Are you usually able to get around in your own home? 20. Are you usually able to get around in your own neighborhood? 21. Are you usually able to shop for groceries? Editors Note: Sample form adapted from Clemson Ophthalmology, Clemson, SC, and the American Society of Cataract and Refractive Surgery.

Tests Help with Medical Necessity

In addition to the questionnaire, there are one or two tests that help to substantiate medical necessity:

1. The vision test: For vision, most carriers require a best corrected vision of 20/50.

2. The glare test: If the acuity level is 20/40, there would also have to be a documented glare test showing that the vision drops to 20/50 or worse under glare conditions (which the patient would report in the interview as problems such as difficulty driving at night due to glare from headlights or late-afternoon driving into the sun). If the acuity level is 20/50 or worse and there is a patient complaint of interference with daily living activities, that constitutes medical necessity.

Note: There are no codes for visual acuity or glare tests; these are included in the office visit.