Understanding Optometric Visit Coding. Ronald J Purnell MBA COE OCS

Transcription

1 Understanding Optometric Visit Coding Ronald J Purnell MBA COE OCS

2 Ron BA, MBA, COE, OCS Optometric, ophthalmic work history Experience in almost every area Front office, phones, check in/check out Back office, coding reimbursement Technical, surgical assisting 1990 s - current audit experience, OIG

3 Please Remember This material can, and will change. Verify the material you receive with the NCCI, LCD s, NCD s, CPT, an attorney and common sense. An hour lecture does not allow a full disclosure of all billing rules and regulations in ophthalmology, optometry, or medicine. We will be discussing the most common rules, there are others out there. Your mileage may vary.

4 Historical Prospective How far back does this all begin?

5 Historical Prospective 1592 Plague 1603 London Bills of Mortality Bill or Barter (1 chicken) Usual, Reasonable and Customary CPT

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7 2012 OIG Work Plan Coding of Evaluation and Management Services We will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, , providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics. (OEI; ; expected issue date: FY 2011; work in progress

8 OIG Work Plan Payments for Evaluation and Management Services We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. (OEI; ; ; expected issue date: FY 2012; work in progress)

9 RAC AUDIT What percent of claims are overpaid? 1) 10% 2) 35% 3) 65% 4) 90%

10 RAC Pilot Program 96% of claims were overpaid. 1 Billion in overpayments Cost 20 cents per dollar collected Contingency Fee basis In all states since 2010 (No focus on eye, yet)

11 Medical Record Basics Legible Dated Identity of provider Reason for the visit Assessment Plan

12 Let s Create a Code Set.

13 Optometric Visits Evaluation & Management The Eye Codes Comprehensive (new and established) Intermediate (new and established) HCPCS Codes S0620 Routine Eye with refraction New Pt S0621 Established Pt

14 Evaluation and Management Levels 1 5, new and established. Used in a bell curve format. Level 1 not requiring the presence of a physician. Level 5 OMG, infrequently used

15 New Patient Eye Exams Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits

16 Established Patient Eye Exams Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits

17 Intermediate Ophthalmological Services "Intermediate ophthalmological services describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy."

24 Comprehensive Ophthalmological Services "Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. (Continued)

25 Comprehensive Ophthalmological Services The service includes history, general medical observation, external and ophthalmoscopic examination, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

26 Comprehensive Ophthalmological Services "Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session.

27 Comprehensive Ophthalmological Services "Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session.

35 The little tax deduction

36 The little tax deduction 1. Ron 2. Nona 3. Our son, Benton 4. Gemini the dog 5. Sputnik the cat

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38 5 Steps to Selecting Appropriate E&M codes/services Step 1.- Type of Service: What type of service is the patient receiving? (office visit, consultation etc.) Step 2.- New or Established: If this is an office visit, is this a new or established patient? Step 3.- Key Components: What level of the key components (history, examination, medical decision making) have been met or exceeded Step 4.- Time: Will time determine the level of E/M service? Step 5.- Documentation: Document! Document! Document!

39 E & M a closer look 1. History History 2. Examination Exam 3. Medical Decision Making 4. Counseling 5. Coordination of Care 6. Nature of Presenting Problem 7. Time MDM

40 1. History History The Chief Complaint (CC) The History of The Present Illness (HPI) The Review of Systems (ROS) The Past, Family and Social History (PFSH)

41 The Chief Complaint The Chief Complaint is the reason for the exam. For Medicare patients, it cannot be routine or annual or any variation thereof. There will often be multiple complaints, they should be listed in order of importance. History

42 The Chief Complaint There are two types. Medically necessary (Covered) Routine (Sometimes covered) The best practice is to always use a medically necessary chief complaint History

43 History of the Present Illness 7 dimensions (see handouts) 1. Location (RT, LT, OU) 2. Quality constant, chronic, acute, worsening, lessoning. 3. Severity History

44 HPI Continued History 4. Duration (For three days) 5. Timing (Worse in the mornings etc.) 6. Context (Worse when reading, outdoors, in bright sun.) 7. Modifying Factors (Humidifier, artificial tears, what makes it worse or better.) 8. Associated Signs and Symptoms (Headache, lid twitch, scintillating vision.)

45 History of the Present Illness There are 2 types of HPI s Brief 1 to 3 elements are documented. Extended 4 or more elements are documented. The best practice is to always have 4 Doctor time is lessened. (So, what brings you here today?) History Billing is unconstrained. (Any level, any visit)

46 Review of Systems History Eyes Gastrointestinal Hematological/ Lymphatic Constitional Genitourinary Allergic/ Ears, Nose, Mouth, Throat Integumentary Skin and/or Breast Immunological Psychiatric Cardiovascular Neurological Endocrine Respiratory Musculoskeletal All others negative

47 None Review of Systems Pertinent to Problem 1 system Extended 2 to 9 systems Complete 10 systems or more (May use all others negative. History

48 Past History (PFSH) Illnesses, injuries Prior surgery Prior hospitalizations Current Meds Allergies (food, drug, environmental) Immunizations Feeding/dietary status History

49 Family History (PFSH) Hereditary diseases in family Diabetes Glaucoma Cataract History

50 Social History (PFSH) Use of Drugs, Alcohol or Tobacco Current Employment Developmental History Marital Status Other relevant social factors Lives alone Drives car History

51 Exam There are 2 guidelines Exam 1995 which involves all of the systems. Very Unlikely To Be Used By An Optometrist! You want to know WHAT! 1997 The Single Specialty Exam Let s just stick with that for ease of use.

52 Exam Single Specialty - Eye Problem Focused 1 5 bullets Expanded Problem Focused 6 9 bullets Detailed 9 12 bullets Comprehensive all eye elements and mental status Exam

53 2. Examination Exam 1. Test visual acuity (Does not include determination of refractive error) 2. Gross visual field testing by confrontation 3. Test ocular motility including primary gaze alignment 4. Inspection of bulbar and palpebral conjunctivae 5. Examination of ocular adnexae including lids (ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes

54 2. Examination Exam 6. Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (anisocoria) and morphology 7. Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film 8. Slit lamp examination of the anterior chambers including depth, cells, and flare 9. Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus

55 Exam 2. Examination 10. Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) 11. Ophthalmoscopic examination through dilated pupils (unless contraindicated) of 12. Optic discs including size, C/D ratio, appearance (atrophy, cupping, tumor elevation) and nerve fiber layer 13. Posterior segments including retina and vessels (exudates and hemorrhages)

56 2. Examination 14. Orientation 14. Time 15. Place 16. Person 15. Mood and Affect Exam

57 3. Medical Decision Making 3 core components 1. Number of Dx and Mgmt Options 2. Amount/complexity of Data 3. Table of Risk 1. Presenting Problems 2. Diagnostic Procedures Ordered 3. Management Options MDM

58 Medical Decision Making 1. Number of Diagnosis and Management Options Self Limited/Minor: Stable, Improved, Worsening Established Problem: Stable or Improved Established Problem: Worsening New Problem: No Additional Workup Planned New Problem: Additional Workup Planned MDM

59 Medical Decision Making MDM 2. Amount/Complexity of Data Lab Work Ordered/Reviewed (Sed Rate)? Ultrasound or Radiology? Tests Ordered (VF, OCT, GDX)? Tests Reviewed with Other MD/OD? Independent Review Image, Tracing, Specimen? Records Obtained (Other MD/OD, Family Member)? Records Reviewed (Other MD/OD, Family Member)?

60 Medical Decision Making 3. Table of Risk Minimal Low Moderate High MDM

61 Counseling Coordination of Care Time Face to Face Physician Time (not tech time, not door-to-door time) More than 50% of the encounter minutes minutes minutes minutes minutes

62 E & M or Eye Codes Which one should I use? 1. Just E & M? 2. Just Eye? 3. A mixture?

63 Are you an error prone provider? 1. Yes, I would be considered an error prone physician. 2. No, I make very few errors and would not fall into the error prone physician category.

64 Error Prone Defined as providers that had at least one error in each of the last 4 years of our audit period Office of Inspector General

65 CPT Medicare Utilization Rates New patients % CPT Est. Patients Level 5 3% Level 5 1% Level 4 30% Level 3 Comp Eye Level 2 Int. Eye % Level 4 Comp Eye Level 3 Int. Eye % 50% 44% 6% Level 2 4% Level 1 1% Level 1 1%

66 Financials Comparison (Established Patients NY 2012) $ $ $ $ $ $ $158.94

67 Financials Comparison (New Patients NY 2012) $ $ $ $ $ $ $226.26

68 2009, 2010, 2011, 2012 Established Patient Intermediate $95.69 New Patient Intermediate $90.96

69 Questions

70 Thanks!

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