Ophthalmology and Optometry Coding Alert

Use these tips to make turning abbreviations into codes much easier

Do you know your OP from your KP? If not, you may need a crash course on ophthalmology acronyms. If you can't differentiate between the abbreviations in your physician's chart, you could be applying the wrong codes to your claims.

     
Because ophthalmology coders encounter numerous acronyms when reading, coding and evaluating medical charts, we take for granted that we can decipher most of the abbreviations and acronyms that we come across. But even the most experienced ophthalmology coder can benefit from a primer that outlines the most common abbreviations.

     
Review the following two examples, and see if you can figure out what the surgeon did:

• 35 y.o. new pt. requires examination. CC is BS. Pt. Previous dx: AODM.

• IOL exchange. 65 y.o. est. pt. due to incorrect power.

The answers: Translated into real-world terminology, the first ophthalmologist saw a 35-year-old new patient requiring examination and evaluation due to a chief complaint of a blind spot in her vision. The patient has a previous diagnosis of adult onset diabetes mellitus.

     
The second example involves a 65-year-old established patient who required an intraocular lens exchange due to incorrect power of the first lens.

When in Doubt, Clarify

Medical terminology has developed over hundreds of years into an ever-increasing number of words and phrases. With the explosion of technologies over time and the unfortunate explosion of new diseases, injuries and other types of illnesses came the newer and/or modified terms to deal with the various diagnoses and procedures.

     
Because of the extended disease and procedure names, physicians generated a system of communication using acronyms and abbreviations to facilitate more efficient communication among other medical professionals.

     
What is it? An acronym is a word formed from the initial letter (or letters) of words in a phrase or multi-word description. Contractions or abbreviations are shortened forms of a word or phrase, usually used to reduce the amount of time spent writing or dictating.

     
Unfortunately, in addition to being more efficient, the onslaught of acronyms has increased the possibility of error because of misunderstandings of the acronym or abbrevia-tion. Often, you can discern the meaning from the abbreviation's use. For example, ophthalmology coders would rarely confuse the "chief complaint" with "costo-chondral," although physicians often use "CC" for both.

     
Solution: If you are ever confused by a medical acronym, always ask the physician rather than guessing.

Compile Internal Acronyms

Caution: "When a carrier requests documentation to support E/M or procedural services rendered, acronyms that are internally created may be misinterpreted or not understood by the reviewer," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla.

     
Best practice: If your office has its own internal acronyms, ask the physician to translate them and distribute the list throughout your office. Many ophthalmology offices use their own "unpublished" acronyms and abbreviations that you might know but a newer staff member might not be able to figure out. Try to overcome carrier and staff confusion by limiting the number of internal acronyms your ophthalmologist uses.

Note: See "Let This Tool Guide You When You Encounter Acronyms" below for a list of some of your ophthalmologist's favorite phrases.