Ophthalmology and Optometry Coding Alert

Question: Our office performed an audit prior to submitting our claim to insurance and we discovered that the doctor marked a 99215 even though the level only met the requirements for 99214. The doctor has received one-on-one training, and it has been explained what constitutes a level five. Is it acceptable for the doctor to make amendments to the note so that the claim can be filed as a 99215, or should it be considered as a training opportunity and the 99214 should be billed without the doctor going in and amending the note?

Also, is it acceptable for a physician to consistently reach a level five by utilizing the option under amount and complexity of data reviewed to review and summarize old records and/or discussion with another health care provider? For example, any time a patient is seen as a follow up to a hospital or ER encounter the doctor summarizes the report, then typically orders lab and x-ray and then meets a high level on number of diagnosis and management options. Thank you.

Codify Subscriber

Answer: In answer to your initial question, it is not appropriate for the physician to amend the note to reach the higher undocumented level of service. The purpose of the audit result is education, not recoding. In addition, any amendments to the note must clearly document when it was done, but more importantly, the physician would also have to document WHY he had to amend the note. The amendment needs to be for a medically justifiable reason (such as, reporting the incorrect medication or failing to document a test that was ordered).

As to the second question, you will have to determine how to handle this based on a well thought-out protocol, and then in the end, the physician must be able to adequately defend his billing level via medical need to provide these highly complex services, but you should always code based on both the documentation and the medical necessity of the visit. Simply boosting the level of management options isn’t enough to consistently report high-level codes--there must be a reason the doctor ordered all of the tests.

Don’t forget: Medical Decision Making (MDM) is only one component of the entire physician-patient encounter. If high MDM is documented and supported by medical necessity, the other two components will play a role in determining the overall level of E/M code assignment. And although it is always possible to achieve a comprehensive level for the examination, the bottom line is “was it necessary to perform a comprehensive exam?”