Ophthalmology and Optometry Coding Alert

Question: I have a payer that routinely downcodes our E/M services. What can I do about this problem?

Alabama Subscriber
 
Answer: First, check your contract with the managed-care organization to determine if the MCO is permitted to do this. If the contract doesn't discuss the issue, write to the payer and request the basis for the downcoding, with specific deficiencies determined from the documentation - history of present illness, review of systems, past, family and social history, exam or medical decision-making.
 
Also, ask for a copy of its E/M documentation requirements. If the MCO has downcoded your claim without reviewing the documentation, this is inappropriate. Appeal the claim with a copy of the documentation supporting the level of service you originally coded.
 
Insurers downcoding a level four to a level three is a common complaint, but physicians sometimes don't understand the difference between these two levels. To qualify for a level-four E/M visit, the ophthalmologist must perform more work and make a higher level of MDM. This may be necessary for a patient who presents with multiple diagnoses. The physician must perform and document the qualifying criteria. If the documentation does not support a level-four E/M code, report only the level the documentation does support.
 
Report routine downcoding to your county and state medical societies. You may find that this is a common problem in your area and that the medical society is already working on it.

 - Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, president of Practice Solutions, Santa Barbara, Calif.