Transcript Document

Medical Records Coding:
Choosing 92000 Codes Accurately
Charles B. Brownlow, OD, FAAO [email protected]
January 10, 2013
Plan of Action
for this Webinar Series
• Part I: November 29, “The Reality of Audits”
• Part II: December 17, “Building Your Medical
Records Compliance Program”
•Part III: January 10, “Medical
Records Coding…the 92000
Office Visit Codes”
Multiple Roles of
Today’s Medical Records
• Excellent patient care
• Excellent internal communication
(patient/docs/staff)
• Excellent external communication (other
providers/caregivers)
• Accurate choices of procedure and
diagnosis codes
• Compliance with national rules (CPT/ICD-9)
• Compliance with rules of Medicare and
other insurers
National Resources
• Current Procedural Terminology, CPT© American
Medical Association
– Only nationally accepted source for definitions
and codes for choosing and reporting visits and
procedures
• International Classification of Diseases, 9th Edition
– Only nationally accepted source for diagnosis
codes
• Healthcare Common Procedure Coding System
(HCPCS)
– Level I = CPT codes
– Level II = products, supplies, services not in CPT
More Resources…
• Centers for Medicare and Medicaid Services,
www.cms.gov
– Medicare Learning Network resources
• Evaluation and Management Services Guide,
December 2010 (99000 office visit codes)
• Medicare Fraud & Abuse: Prevention, Detection
and Reporting
• American Optometric Association
– aoa.org/coding
– [email protected]
– Monthly webinars, usually 2nd/4th Tuesdays, 11:00
a.m
The Logic of
Documentation
• Knowing the rules ensures that you do
things correctly, on purpose
• Knowing the rules and applying them
will help you create better records
• Knowing the rules will make you far
more confident when you are audited
by Medicare or other payers
The ‘Logic’
of Documentation
• Every record must include
– The site of service
– The medical necessity of services provided
– Accurate, thorough, legible record of all that
happened during the encounter
• Case History
• Physical Examination
• Medical Decision Making
• Subjective/Objective/Assessment & Plan
(SOAP)
• Date and legible identity of the observer
Logic…
• Rationale for services should be documented or
easily inferred
• Patient’s past and present conditions need to be
available to the physician
• Health risks should be identified
• Patient’s progress, revisions in treatment, diagnosis
changes should be documented
• All codes used for reporting the care must be
supported by documentation and chosen based
on national rules
“Reasonable
and Necessary”
• Nothing should be billed unless it was
reasonable and necessary
– Furnished because it was related to the
identifying of, direct care of, and
treatment of the patient’s medical
condition (not for the convenience of the
patient, physician)
– Compliant with the standards of good
medical practice
Reporting Eye Care Visits
• Visits may be reported with either of two
sets of codes
– General ophthalmological services
• Intermediate, 92002 (new)/92012(established)
• Comprehensive, 92004 (new)/92014 (established)
– Evaluation and Management Services
• New patient services, 99201-99205
• Established patient services, 99211-99215
Note: New patient is one who has not been seen by you or
another doctor of exact same specialty here or in
another practice of same ownership in previous three
years, date to date
Choosing a 92000 Code
• As with all services, we must use these
codes only when the documentation
matches the definitions in CPT
• Most visits can be reported using either
99000 or 92000 codes (70-80%)
– Approximately 20% of the eye doctors’
charts we review are missing at least one
requirement for the intermediate or
comprehensive ophthalmological services
and can only be coded as a 99000 visit
92000 Codes: General
Ophthalmological Services
• General Ophthalmological Service codes, as
all other CPT codes, are designed to report
medical eye care visits
• General ophthalmological service codes may
be used to report non medical eye care
• Refraction is a separate service (92015) and
is not included in any other code, unless
required by contract with payer
CPT Definition
for Intermediate
Ophthalmological Services
Note: Current Procedural Terminology(CPT ©
American Medical Association) is the only accepted
source of definitions for these 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…with initiation
(or continuation) of diagnostic and treatment
program.”
New (92002) or established patient (92012)
CPT Requirements
for 92002/92012
Payers may develop their own interpretations of
these definitions, but the elements that are
clearly included in the CPT definition are:
1. A new or existing condition…
2. complicated with a new diagnostic or management
problem not necessarily relating to the primary
diagnosis
3. History
4. General medical observation
CPT Requirements
for 92002/92012
5. External ocular/adnexal examination
6. Other diagnostic procedures as indicated
7. Initiation (or continuation) of a diagnostic and treatment
program
If one (or more) of these elements is missing, the
visit cannot be coded as intermediate
ophthalmological service.
CPT Definition
for 92004/92014
• “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. The service includes history, general
medical observation, external and ophthalmoscopic
examinations, 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.”
• New (92004) or established (92014) patient
CPT Requirements
for 92004/92014
Again, payers may develop their own
interpretations of these definitions, but the
elements that are required by the CPT
definition are:
General evaluation of the complete visual system
1. History
2. General medical observation
3. External examination
4. Ophthalmoscopic examination (with or without
cycloplegia or mydriasis)
CPT Requirements
for 92004/92014
5. Gross visual fields
6. Basic sensorimotor examination
7. Initiation of diagnostic and treatment
program
If one (or more) of these elements is missing,
the visit cannot be coded as comprehensive
ophthalmological service.
Initiation of Dx/Tx Program
Is Critical Component of Medical Record
• Most likely target of reviewers/auditors of eye
care records
• Visit will be downcoded or rejected if coded
as ophthalmological service and without
initiation of diagnostic/treatment program
• No detailed nationally accepted, detailed
definition, so…
– Every office must have their own definition of
what’s included in initiation (continuation) of
diagnostic and treatment program
Your Office’s
Definition of Initiation of
Initiation of Dx/Tx Program Is…
• Probably will include 15-20 items, ie:
– Diagnoses pertinent to today’s visit
– RTO
• For recheck
• For additional tests
• For treatment
– Rx meds
– Rx specs
More Dx/Tx
– Rx CLs
– Refer for Dx/Tx
– Recommended OTC meds
– Lid hygiene, lid scrubs, etc.
– Ergonomic adjustments at work or home
– Adjustments in school environment
– Refer to another doctor or clinic for Dx/Tx
– Etc.
Auditors are
‘Focused’ on the 92000 Codes
• Why?
– Many ODs and OMDs use them almost
exclusively
• Why is that a problem?
– 15-20% of the charts we review are missing at
least one required element of the 92000 codes
– Most ODs and OMDS have never read the CPT
definitions for the codes
– Auditors love to challenge doctors’ ‘initiation of
diagnostic and treatment program’
And in Conclusion…
• There are lots of things to learn with respect
to medical record keeping, coding, claims
submission, Medicare and other payer rules.
• There is no alternative to learning, carefully
doing, and properly reporting
• It takes effort, but it’s not that tough and it is
well worth the effort, in better patient care,
better communication, enhanced revenues
for the practice, better relationships with the
payers, and in improved peace of mind!
Next Month’s Webinar…
Choosing a 99000 Code
• CPT definitions are more subjective
• Documentation Guidelines for the
Evaluation and Management Services
add more details to the definitions
• As with all codes, 99000 visit codes must
be billed only when the content of the
record matches the CPT definition for
the code
Procrastination is passé
• Most providers have ignored this stuff too
long
– Commit all doctors and staff in your practice to
focusing on patient care and compliance with
national rules and payers rules
– Conduct internal audits of each doctor’s charts
each 3-6 months (e.g. 5-10 charts/audit)
– Develop in-office protocols to ensure consistent
record keeping and compliance with payers’
rules
Additional webinars in this series
will be based on your feedback
and on current medical records
challenges facing eye care providers
Questions?
[email protected]