Optometry Coding & Billing Alert

Published on Mon Aug 23, 2004 PDF

The key to getting your diagnosis codes right is knowing the exact condition the optometrist is treating, identifying it in both the alphabetic index and tabular index, and selecting the most specific possible code. Here's how to keep your diagnosis coding accurate:

1. Scrutinize the optometrist's notes to find the signs, symptoms or condition. You want to look for the reason for the encounter. If the optometrist doesn't note a definitive diagnosis, code the symptoms.

Pull all signs, symptoms and conditions from the office visit note. The signs, symptoms and conditions you pull from the note provide medical necessity for the tests - your key to reimbursement.

Word to the wise: You should not code conditions defined as "rule out," "suspected," "probable," "questionable" or "possible" in the physician office setting. Coding for a rule-out diagnosis can falsely label a patient with a condition that he does not really have. And  Medicare and private payers will not accept rule-out diagnoses because they prefer to see that the optometrist is investigating the patient's signs and symptoms, rather than a specific suspect diagnosis.

"We don't code for rule outs at all," says Marsha H., a biller with Sussex Eye Center in Selbyville, Del. And if the optometrist does happen to write "rule out glaucoma," for example, he would report a glaucoma suspect code such as 365.01 (Open angle with borderline findings) - and that's different from coding a condition defined as a rule out, she says. Instead of a rule out, code for any signs or symptoms the patient has - no matter how seemingly minor they are.

2. Find the patient's condition in the Index to Diseases (Volume 2 of the ICD-9 manual). Always begin your code search from the Index, says Joann Baker, CCS, CPC-H, CPC, CHCC, owner of Precision Coding and Compliance in Flanders, N.J. Starting with the Index helps to ensure the highest level of specificity, which is your ultimate goal.

3. Locate your code in the Tabular List (Volume 1 of the ICD-9 manual). "Verifying your code in Volume I is an important step," Baker says. "There are additional notes, guidelines boxes, and cross references that you should review prior to making your code selection."  

4. Verify that you've got the most specific code for the condition. Your final task is to select the code with the highest level of specificity, which often includes assigning a fourth or fifth digit.

Keep it orderly: Proper sequencing of your diagnosis codes is important for reimbursement. Whenever the optometrist documents a definitive diagnosis, you should report that ICD-9 code as the primary diagnosis. Always list signs and symptoms as secondary, unless there is no definitive diagnosis to list first.