Patient Complaints and Evaluations

Patient Perception and Complaints

• Chief complaints like "trouble walking" or "leg pain" need thorough evaluation beyond patient perception.
• Patient's belief that new glasses will solve vision issues indicates underlying conditions like myopia or AMD.
• Focus on the actual symptoms (e.g., blurred vision or headaches) rather than patient assumptions.

Narrative of Present Illness (NPI)

• NPI is a chronological account of the patient's illness from initial symptoms to current status, guiding treatment decisions.
• Documentation can be done by both doctors and technicians.
• Important NPI Checklist components:
  • Location of the problem (unilateral or bilateral eyes).
  • Duration of the issue.
  • Contextual factors (associated activities).
  • Modifying factors (conditions that alleviate or worsen symptoms).
  • Quality of the problem nature.

Amending Medical Records

• CMS recommends documenting all relevant entries at the time of service; amendments should clearly indicate changes made post-visit.
• Original entries must remain intact, marked with a single strike through in paper records and tracked in electronic records.
• Correctly document the date and author of amendments.

ICD-10 Coding and Diagnosis

• Use specific ICD-10 codes for accurate billing purposes; organized by body system, laterality, and severity.
• Example ICD-10 Codes:
  • H52.223 for bilateral regular astigmatism.
  • H35.3131 for early dry stage, nonexudative age-related macular degeneration.
• Importance of avoiding unspecified laterality codes for clarity.

Types of Patients in Billing

• New Patients: Never seen in the practice or not seen for over three years.
• Established Patients: Seen by any practitioner in the practice within the last three years.

Ophthalmological Exam Codes

• Primary codes for ophthalmological exams include:
  • 92002: Intermediate medical examination for new patients.
  • 92004: Comprehensive examination for new patients.
  • 92012: Intermediate examination for established patients.
  • 92014: Comprehensive examination for established patients.

Medical Necessity in Documentation

• Document services with clear medical necessity for payment approval.
• Ensure test justifications align with documented diagnoses to avoid billing issues.

S-Codes for Routine Exams

• S-Codes enable billing for routine eye exams with lower complexity, used when medical necessity is not established.
• Provide a structured alternative for routine wellness care, differing from more complex codes.
• Ensure compliance with state standard care guidelines despite confusions with similar procedures for varying patient needs.

Claims Submission Process

• Collect patient's demographic data and insurance details from intake paperwork.
• Copy or scan the front and back of the insurance card for policy and contact information.
• Consider scanning or copying IDs of patients or their legal guardians for verification.

Submission Methods

• Directly through Insurer Portals:

  • Utilize online provider portals for submitting claims, which is the fastest method.
  • Access eligibility information before submission to ensure accurate claims.
  • Example: Availity.com serves as a third-party portal for many insurers.

• Indirectly through Clearinghouses:

  • Use if insurers lack a straightforward portal or if their portal is complex.
  • Clearinghouses act as intermediaries between the office and insurance companies.
  • Benefits include:
    • Claim scrubbing to check for coding errors.
    • Batched submission of prepared claims.
    • Electronic information exchange with insurers.
    • Management of claim rejections or denials.

• Manual Submission:

  • Offered as an option only when no direct portal or clearinghouse is available.
  • Requires filling out a claim form and submitting it via fax or postal mail.
  • This method is less efficient, likened to outdated practices.

Claims Submission Process

• Collect patient's demographic data and insurance details from intake paperwork.
• Copy or scan the front and back of the insurance card for policy and contact information.
• Consider scanning or copying IDs of patients or their legal guardians for verification.

Submission Methods

• Directly through Insurer Portals:

  • Utilize online provider portals for submitting claims, which is the fastest method.
  • Access eligibility information before submission to ensure accurate claims.
  • Example: Availity.com serves as a third-party portal for many insurers.

• Indirectly through Clearinghouses:

  • Use if insurers lack a straightforward portal or if their portal is complex.
  • Clearinghouses act as intermediaries between the office and insurance companies.
  • Benefits include:
    • Claim scrubbing to check for coding errors.
    • Batched submission of prepared claims.
    • Electronic information exchange with insurers.
    • Management of claim rejections or denials.

• Manual Submission:

  • Offered as an option only when no direct portal or clearinghouse is available.
  • Requires filling out a claim form and submitting it via fax or postal mail.
  • This method is less efficient, likened to outdated practices.

This quiz focuses on analyzing patient complaints, specifically their perceived solutions to chief complaints such as trouble walking or visual issues. Understanding the actual experiences behind these complaints is crucial for effective evaluation and diagnosis. Explore how to accurately interpret patient statements in a clinical context.