Coding and Billing PDF

CODING AND BILLING Coding refers to the standardized numeric and alpha-numeric systems that are used to identify specific items and procedures furnished to a patient. For example, you no longer do a refraction, you perform a 92015 (determination of refractive state) and you no longer take fundus pho...

CODING AND BILLING Coding refers to the standardized numeric and alpha-numeric systems that are used to identify specific items and procedures furnished to a patient. For example, you no longer do a refraction, you perform a 92015 (determination of refractive state) and you no longer take fundus photos, you order and perform 92250 (fundus photography with interpretation and report). Billing refers to the submission of these codes on a claim for adjudication by the payer and subsequent reimbursement to the provider. There are a variety of coding systems currently in use. When billing third-party payers for optometric care, we will prepare claims by listing procedures performed using CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes linking them to ICD-10 diagnosis codes. According to the Medicare Claims Processing Manual, the rules for reporting diagnosis codes on your patient's claim are as follows: Use the code that describes the patient's diagnosis, symptom, complaint, condition, or problem. Do not code a suspected diagnosis. The physician should code the ICD-10 code that provides the highest degree of accuracy and completeness. Use the code that is chiefly responsible for the item or service provided. Assign codes to the highest level of specificity. Use the appropriate laterality where applicable. Code a chronic condition as often as applicable to the patient's treatment. Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.) In concept, for some plans the "reason for the visit" determines the coding but just because someone comes in for a "vision check" does not mean that they will not have legitimate medical eye complaints or issues discovered somewhere during the exam that are significantly contributory to the worsened vision. Examples of medical complaints: dry eyes, scratchy eyes, eye pain, watery eyes, spot/bump on eye, loss of vision, distorted vision, drooping lids, floaters, flashes, headache, photophobia, asthenopia, redness, pressure, etc. Many people will have a medical complaint if you ask them. A large percentage of your patients probably have no idea that their eye condition can be covered by their medical insurance. To them, a visit to an eye doctor DOCUMENTATION Medical record documentation is essential for recording pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is a crucial element in providing high-quality health care. It facilitates: The ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment and to monitor their health care over time. Communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care. Accurate and timely claims review and payment. Appropriate utilization review and quality of care evaluations. The collection of data that may be useful for research and education. An appropriately documented medical record can reduce many of the hassles associated with claims processing and may serve as a legal document to verify the care provided, if necessary. Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate: The site of service. The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. The services provided have been accurately reported. Patient History Have your patients fill out a comprehensive medical history questionnaire. Choose a form that efficiently gathers information about their chief complaint. During subsequent visits, you will reference the initial medical history questionnaire; however, the patient is not required to complete a new one each time. In my office, we have patients fill out a new history form every three years or sooner if significant changes occur—other doctors may request a new form annually. Many doctors make their medical history questionnaires available on their websites for patients to download. There are numerous examples of good medical history forms available online. Establishing a Chief Complaint A chief complaint is a concise statement that summarizes what the patient is experiencing that brought them in for their visit. It determines what type of examination needs to be performed and how it will be subsequently billed. The definitions of chief complaint in the Current Procedural Terminology (CPT) code set maintained by the American Medical Association (AMA) and from the Centers for Medicare & Medicaid Services (CMS) are very similar. The AMA CPT code set defines the chief complaint as: "A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words." The CMS definition is: “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter.” The type of examination should be determined by the patient's chief complaint. Document the chief complaint accurately and bill accordingly. For instance, if the chief complaint in the chart indicates that the patient is presenting for a routine exam for glasses, perform a routine examination for glasses. The patient may be presenting for a doctor-ordered twelve-month diabetic reassessment, or they may have scheduled the appointment themselves due to noticing vision changes, or they may simply want to get a different style of glasses frames. Follow-up questions are necessary to understand the true nature of their presenting issues. When the patient calls to make their appointment, have the front desk note their reason for coming in. This begins the process of establishing their chief complaint and helps the staff understand the issues they are experiencing and their expected treatment. It could be for glasses, contacts, or a medical problem evaluation. Understand that patients might have vision problems stemming from a medical issue for which they think glasses are the solution. Given the potential dual nature of eye problems, always collect both vision and medical insurance information. Examples of Establishing a Chief Complaint Example 1 Dr's Office: What brings you in today? Patient: I need new glasses. Dr's Office: What kind of issues are you having? Patient: The coating is flaking off my lenses, and I think my frame is going to break any minute now. Dr's Office: Are you having any vision problems? Patient: Not really. Chief Complaint: No vision issues, coating flaking off lenses, frame worn. Exam: Routine 92004. Diagnosis: H52.03, H52.223, and H52.4. Example 2 Dr's Office: What brings you in today? Patient: I need new glasses. Dr's Office: What kind of issues are you having? Patient: I've noticed some problems driving at night and reading. I need lots of light. Chief Complaint: Blurred vision driving at night, needs lots of light when reading. Exam: Routine or medical 92004. Diagnosis: Early cataract H25.13. Example 3 Dr's Office: What brings you in today? Patient: I'm here to change my glasses because I started seeing blurry in my left eye this morning. Dr's Office: That blurred vision started this morning? You woke up that way? Tell me more about that. Patient: Yes, I can't really see out of my left eye since I woke up this morning. That's why I think my glasses need to be changed. Chief Complaint: Recent onset OS blur x 1 day, blurry in left eye since this morning. Exam: 99214. Diagnosis: H43.12 (vitreous hemorrhage, left eye), E11.3592 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye). Example 4 Dr's Office: How's everything going with your blood sugar and overall diabetes management? Patient: Pretty well, I think. I've been keeping my A1c below 6. Dr's Office: That's great! Are you having any issues with your eyes or vision? We discussed your cataracts last year; are you noticing any significant changes? Patient: Not really. Chief Complaint: Doctor-ordered reassessment of diabetes. Patient reports no issues with eyes or vision. Exam: 99214. Diagnosis: E11.9, H25.13. Understanding that breaking their glasses may be why they are no longer able to subjectively overcome blurry vision or headaches, it is essential to identify the true chief complaint. Your role is to determine whether it’s myopia, AMD, or another condition, rather than letting the patient’s self-diagnosis control the examination or billing. History of Present Illness (HPI) The HPI is a chronological description of the development of the patient’s present illness from the first sign or symptom or from the previous encounter to the present. It typically drives a provider’s decisions about the physical examination, diagnostic tests, and treatment. The HPI should be documented by the doctor but can also be documented by techs. HPI Checklist: Identify the eye(s) in which the problem is located. Determine how long the problem has been occurring. VISION.  Here’s the revised version: PATIENTS TEND TO THINK THEIR VISION PROBLEMS ARE REFRACTIVE IN NATURE AND THAT GLASSES ARE THE SOLUTION. When they walk in and say they need new glasses, they are ultimately expressing that they aren't seeing as well as they expect, and their perceived solution to their visual issue is "new glasses." For comparison, saying "I need crutches!" isn't a chief complaint. It’s a description of the patient's perceived solution for their chief complaint, which might be "I’m having trouble walking" or "I’m experiencing leg pain." What the patient is actually experiencing is what needs to be noted and evaluated. "Broken glasses" or "I need new glasses" is simply the patient’s way of indicating they are currently experiencing reduced visual acuity and believe new glasses should resolve the issue. Exam: 99214, Diagnosis: E 1.9, H25.13 Breaking their glasses may be why they’re no longer able to subjectively overcome their blurry vision or headache or whatever, but it's those headaches or the blurred vision that is the chief complaint. Your job is to determine whether it's myopia, AMD, or a stroke and their notion of what it might taźe to doesn't negate the actual condition they're experiencing. The take home lesson here is to get the real complaint and don't let the patient's lack of ability to articulate what's actually going on, control the examination or the billing. Being in charge is your job anğ you're always going to be better at investigating their complaints than they are expressing them. Narrative of Patient Illness The NPI (Narrative of Present Illness) is a chronological description of the development of the patient’s present illness from the first sign or symptom or from the previous encounter to the present. It typically drives the provider's decisions about the physical examination, diagnostic tests, and treatment. The NPI should be documented by the doctor but can also be documented by techs. NPI Checklist: Location: Identify the eye(s) in which the problem is located. Is it unilateral or bilateral? Duration: How long has this been a problem? Context: Is it associated with any activity? Modifying Factors: Is there anything that makes it better or worse? Consider factors such as: Glasses? Removing contacts? Heat? Artificial tears? Other? Quality: What is the nature of the issue? Is it constant, acute, chronic, improved, or worsening? How is the pain? Severity: Describe the pain or redness on a scale of 1 to 10, with 10 being the worst. Associated Signs/Symptoms: Is it causing blurred vision, headache, or twitching? Review of Systems (ROS): ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms that the patient may be experiencing or has experienced. These include: Constitutional Symptoms: (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Past Medical, Family, and/or Social History (PFSH): PFSH consists of a review of three areas. Note that the “M” is missing in PFSH—we're not sure why, it just is. Don't make it weird. Past Medical History - Review of past illnesses, operations, or injuries, which may include: Prior illnesses or injuries Prior operations Prior hospitalizations Current medications Allergies Age-appropriate immunization status Age-appropriate feeding/dietary status Family History - A review of medical events in the patient's family, which may include information about: The health status or cause of death of parents, siblings, and children Specific diseases or conditions affecting family members Diseases related to problems identified in the Chief Complaint, HPI, or ROS that may be hereditary or place the patient at risk Social History - An age-appropriate review of the patient’s past and current activities, which may include significant information about: Marital status and/or living arrangements Current employment Occupational history Use of drugs, alcohol, or tobacco Level of education Sexual history Other relevant social factors Exam Structure - The SOAP Note SOAP notes are one of several styles of documenting your examination. Other styles include DARP, PIE, and DAIR notes. We use the SOAP note style, so we'll discuss it here. The acronym stands for Subjective, Objective, Assessment, and Plan. Following the SOAP format helps create a standard and organized way of documenting all patient information, allowing you to gather information about a patient and make inferences about what’s wrong. Here are the components of and how to write a SOAP note: Chief Complaint: A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter. If you ordered a revaluation and reassessment of their medical condition from last year’s exam, note that here. "Broken glasses' ' is not a chief complaint. Subjective: This is information the patient reports directly to you. The subjective portion is not necessarily factual information and can change over time. It can include the history and details of the eye issues, such as severity of blur and duration, as well as other subjective findings. Place your HPI in this section. Objective: This section consists of what you perform and observe. Place your exam findings here. If you don’t record it, you didn’t do it. Since we trust you know how to perform an examination, we'll move on. Assessment: The diagnoses and likely diagnoses should be included in this section of the note. If a conclusive diagnosis has not been made yet, list possible diagnoses. This section may include additional diagnoses that need to be ruled out. Plan: This outlines the steps to be taken to treat the patient. It should specify the type of treatment and management being offered, such as ordering refraction or contact lens fittings, medications, therapies, and surgeries. It may also include long-term treatment plans, recommended lifestyle changes, and short- and long-term goals for the patient. Order any ancillary testing here as well. Establish medical necessity when ordering a procedure to avoid issues with reimbursement. For example, a good plan might be: "Order refraction to determine best corrected acuity as it relates to the emerging nuclear sclerosis, return for reassessment in 12 months. AMENDING A SIGNED CHART CMS encourages providers to enter all relevant documents and entries into the record at the time of service. However, hey understand that “occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered a6er rendering the service.” When entering new or changed information after the original date of service, you should identify it as an amendment, you should sign and date it. Never delete the original entry. If you're still using paper r»cords, use a single strike line through the original content. For electronic records, you must “provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record,” per cMs. From CMS (Rev. 442, Issued: 12 07-18, Effective: 01-08-13, Implementation: 01-08-19) Corrections or addenda must: 1. Clearly and permanently identify any 'amendment, correction or delayed entry as such, and 2. C/ear/y indicate r/ie date and author of any amendment, correction or delayed entry, and 3. Not delete but instead clearly ’:Identify all original content Paper Medical Records: When co directing a paper medical/ record, these principles are genera//y accomplished by using a single /f e strike through so that the original content is still readable. Further, the author of the alteration must sign and re the''revision. Similarly, amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record. Electronic Health Records (EHR). Nedicâl record keeping within an EHR deserves special considerations; however, the principles wed above remain fundamental and necessary for document submission to NACs, CERT, Recovery Auditors, and ZP(Cs. Records sourced mom electronic systems containing amendments, corrections or delayed entries m st: a. Distinctly identify any amendn ent, correction or delayed entry, and  b. Provide a reliable means to clearly Identify r/ie original content, the modified conrenr, and the date and authorship of each notification o/ r/ie record EXAM CODES - Physical Exam CPT Coding When we send claims to insurers for payment, we need to ensure we maintain accuracy with all of our data. This includes the patient's demographic information, the patient's insurance information, and our claim coding information. We need to accurately document our services and our diagnoses supporting those services. Here’s a brief overview of important considerations: Use ICD-10 Codes: Use the most comprehensive code available. For instance, if a patient has bilateral nuclear sclerosis (H25.13) and bilateral cortical cataracts (H25.013), use the more comprehensive code H25.813, which covers combined forms of age-related cataract, bilateral. Use CPT Procedure Codes: Use CPT codes for all medical care. HCPCS S-codes can be used for routine refractive care, but not every vision plan accepts them. Keep Claims Simple: The insurance world speaks in numbers, not words. Keep your claims clean, simple, and as succinct as possible. Ensure Code Relevance: Make sure diagnosis codes relate to and support the medical necessity of the procedure codes. Handle Claim Denials: If you receive a claim denial, review the listed denial codes on your remittance advice and check your claim for errors.  ICD-10 Coding Overview: As part of recording the encounter in the patient’s chart, we may diagnose them with various conditions. These diagnoses need to be coded to the most specific extent possible using the International Classification of Diseases, Version 10 (ICD-10) codes to bill our claims to insurers. The codes are organized by body system, system section and subsection, laterality, severity, etc. Example Codes: H52.223 - Regular Astigmatism, Bilateral ICD-10 Section: Disorders of the Eye (H00-H59) Specific Code: Astigmatism is found in H52, Disorders of Refraction and Accommodation. Further Specification: Regular astigmatism is in H52.22 and is further specified by laterality: H52.221 (right eye), H52.222 (left eye), and H52.223 (bilateral). Avoid using unspecified laterality codes. H35.3131 - Nonexudative Age-Related Macular Degeneration, Bilateral, Early Dry Stage ICD-10 Section: Other Retinal Disorders (H35) Specific Code: H35.3 for Degeneration of the Macula and Posterior Pole. Further Specification: H35.31 for Nonexudative Age-Related Macular Degeneration. The fifth digit specifies laterality: 1 for the right eye, 2 for the left eye, 3 for bilateral. Codes finish with severity after laterality: 1 for early dry stage, 2 for intermediate dry stage, 3 for advanced atrophic without subfoveal involvement, and 4 for advanced atrophic with subfoveal involvement. Types of Exam Codes: 1. Ophthalmological Codes 2. S-Codes (HCPCS Codes) 3. Evaluation and Management Codes (E/M) Types of Patients: New Patients: Patients who are either new to the practice or have not been seen by any of the practice's doctors in the last three years. Never been to the practice = new patient Seen for services three years ago or more = new patient Established Patients: Patients who have received professional services from you or any other doctor in the same practice within the past three years. Seen for services last year = established patient Seen for services two years ago = established patient Seen for services two years and 364 days ago = established patient Seen for services three years ago = new patient Seen by the same doctor at a different practice three months ago = established patient Seen by another doctor in the same practice two years ago at a previous office = established patient Examples: A patient was last seen for a comprehensive exam four years ago. Two years ago, she presented to the office with a contact lens stuck in her eye. One of the doctors briefly examined her and noted mild inflammation. Since she was seen  by one of the practice’s doctors within the last three years, she is considered an established patient. Examples: A patient was last seen for a comprehensive exam four years ago. Two years ago, she came to the office to have her glasses adjusted. Since she has not been seen by one of the practice’s doctors within the last three years, she is considered a new patient for billing purposes. Ophthalmological Codes: Optometry has four primary ophthalmological exam codes: New Patient Codes: 92002: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient. 92004: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits. Established Patient Codes: 92012: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, established patient. 92014: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, established patient, one or more visits. The decisions regarding examination intensity are based on the following: The clinical judgment of the eye doCTor The patient's history The nature of the presenting problem Also, there is no requirement to associate any special ophthalmological services (92015 or other diagnostic tests) wit h the 92Oxx codes, but that said, listing “order refraction“ in your plan should meet the req‹ iremÎnt for “initiation of treatment or diagnostic testing“. Since most of your patients will be refraĞed, make sure you list that you ordered this in the plan and tie it to a medical dia jnosiś such as H25.13 (nuclear sclerosis) or whatever they have that a refraction would be appropriate to assess. The intermediate examination Eye Codes (92002 and 92012) are composed of several service components: chief complaint history general medical observation visual acuity external ocular exam adnexal exam (Mydriasis may also be included in the intermediate examination.) Intermediate Example A patient was last seen for a comprehensive exam four years ago. She presents to the office today with a chief complaint of feeling like she has a contact lens stuck in her eye. We take a brief HPI (history of present illness) regarding her symptoms and while talking with her, we notice her leR eye is looking red and irritated. We look at her in the slit lamp and note mild inflammation but no contact lens in her eye. We diagnose her with acute conjunctivitis and recommend managing it with artificial tears every hour for the next five days. Intermediate examination, new patient = 92002 Assessment: Acute Conjunctivitis = H10.32 Plan: Alificial tears, OS, q1h x 5 days In the "official" description of the intermediate ophthalmological codes, it is stated that they require "a new or existing condition complicated with a new diagnosis or management problem" however, it has been our experience that you can bill the same diagnosis from visit to follow-up visit using the 92Oxx codes without issue. The comprehensive examination eye Codes (92004 and 92014) have a more extensive list of service components: chief complaint  history general medical observation visual acuity external ocular exam adnexal exam evaluation of the visual system gross visual fields basic sensorimotor tonometry fundus exam (note that a DFE isn't a listed “requirement”, but it's generally accepted medİcally contraindicated and noted as such) initiation of diagnos:ic and treatment program, for which you must have at least one of the following: o prescription of medication o arranging for special ophthalmological diagnostic or treatment services ("order refraction İo determine patient's best corrected visual acuity as it relates to [t e primary diagnosis] - dispensed Rx to patient") o consultation o laboratory procedures o radiological services Comprehensive Example 1 A patient who was last seen two! years ago presents to the office for an eye examination. She has a history of mild cataracts with mild vitreous syneresis in both eyes. We perform our comprehensive ophthalmological service with dilation and note minimal changes in both conditions. We prescribe a new Spectacle Rx and recommend a twelve month RTC (return to clinic). Comprehensive examinaÏion, established patient = 92014 Assessments: BilateraI nuclear sclerosis = H25.13 Bilateral vitreous opacities = H43.393 Plan: Order refract on to determine best corrected VA through the cataracts and vitreal syneresis. Dispenșe Rx to pt. RTC 12 months to eassÎss lens and vitreous changes If you are performing a refractión, speciùcally order the 92015 in your plan and specify why you're ordering it. The refraction is an additional diagnostic test being utilized to determine the patient's BVA (best visual acuity). Example 2 A patient with a history of diabetes who was last seen ten months ago presents to the oĞce for an eye examination. S 1e states her vision seems to have gotten worse in the distance and thinks her glasses need to be changed. We perform our comprehensive exam and note a refractive shift. The retinas are clear of any diabetic changes so we counsel her on responsible diabetic management and prescribe a new speĞacle Rx and recommend a twelve month RTC. 92014 - E11.9 Type 2 diabetes mellitus without complications (I think an argument can be made for E11.39 - Type 2 diabetes mellitus with other diabetic ophthalmic complications but I've never coded a diabetic refractive shiD this way.) 92015 - E11.9 Plan: Counseled pt on appropriate glucose management Order refraction to determine best corrected VA with diabetic changes RTC 12 months to reassess lens and vitreous changes Example 3 A new patient with an Eyemed Vision plan presents for a routine examination. He is found to be nearsighted with astigmatism. His ocular health is unremarkable. Eyemed does not accept S codes for routine care. 92004 - H52.13 92015 - H52.13 Plan: Rx dispensed to pt, RTC 12 months to reassess Specifically "order" the 92015 in your paln: "Order refraction to determine patient's best corrected visual acuity as it relates to [the diagnosis you're tying it to on your claim] - dispensed Rx to patient " -> Specify why you're ordering it. The Importance of Medical Necessity When documenting your services, always keep in mind that medical necessity is required for providing those services and ultimately for payment. Pay attention to your chart documentation to ensure that your testing is supported by medical necessity and is appropriately recorded in the patient's chart. For example, H4O.013 (open angle with borderline findings, low risk, bilateral) would be a legitimate diagnosis suppoling the need for retinal photos (92250) but H43.393 (other vitreous opacities, bilateral) would not. HO4.213 (epiphora due to excess lacrimation, bilateral) would support 68801 (dilation of lacrimal punctum, with or without irrigation) whereas H53.143 (visual discomfort, bilateral) would not. The S-Codes The use of S codes provide for a routine eye exam INCLUDING REFRACTION at a lower complexity as they are used when medical necessity has not been met. (no medical decision making is required) They are not CPT but rather are heaLthcare Common Procedure Coding system (HCPCS) codes. By using the S-codes, doctors can also set fees for those services at levels diFFerent than for th more complex 92OX4 codes, believing the lower fees to be more appropriate to the level of are provided for those routine patients. The S-Codes are still held to the same standard of care for a complete preventive eye examination as established by our individual state boards. S-Codes perfectly describe routine wellness care, and all vision plans should ideally adopt them as their preferred billing model. However, S-Codes often confuse many doctors who believe that because they perform the same procedures, they have conducted the same exam. This assumption is incorrect. Although the exam elements may be similar, the Medical Decision Making (MDM) required for a 63-year-old patient with cataracts (coded as 92004) is significantly different from the MDM for a 21-year-old myope (coded as 92015). The procedures may be the same, but the thought process and discussion with the patient, such as diagnosis, prognosis, expected course, adjustments, lifestyle concerns, expanded family history, and patient expectations, will differ. The S-Codes are intended for easier, refractive-based, routine wellness exams. Example 1: A 46-year-old new patient presents for a routine eye examination with complaints of difficulty reading near print. After a thorough examination, she is found to have hyperopia with presbyopia. A prescription for spectacle correction to be worn full-time is provided, and she is counseled on her expectations and prognosis. Her ocular health is otherwise unremarkable. Routine eye examination including refraction, new patient: 92002 Assessment: Bilateral hyperopia = H52.03, presbyopia = H52.4 Plan: Dispense Rx to be worn full-time, RTC (Return To Clinic) in 12 months to reassess vision. Example 2: A 20-year-old established patient presents for a routine eye examination. After a thorough assessment, he is found to have a small amount of astigmatism and is given a prescription for spectacle correction to be worn as needed. His ocular health is otherwise unremarkable. Routine eye examination including refraction, established patient: 92012 Assessment: Encounter for examination of eyes and vision without abnormal findings = Z01.00 or H52.223 Plan: Dispense Rx to be worn as needed (PRN), RTC in 12 months to reassess. Encounter for Examination of Eyes and Vision (Diagnosis Codes): This is a good opportunity to discuss the Z codes, which are well-suited for routine care. They are diagnosis codes found in the Z01 section of the ICD-10 manual for encounters involving special examinations without complaint or suspected or reported diagnosis. They include: Z01.0 - Encounter for examination of eyes and vision Z01.00 - Encounter for examination of eyes and vision without abnormal findings Z01.01 - Encounter for examination of eyes and vision with abnormal findings Z01.02 - Encounter for examination of eyes and vision following failed vision screening Medical Decision Making: Medical Decision Making (MDM) refers to the complexity involved in establishing a diagnosis and/or selecting a management option. It is determined by considering: The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical information, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and The risk of significant complications, morbidity, and comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s), and/or possible management options. There are over 11,000 CPT codes that describe medical procedures and services. We will focus on the Office or Other Outpatient Services codes, which range as follows: 99205, 99215 - The highest codes available 99204, 99214 - Moderate to high codes 99203, 99213 - Medium-level codes 99202, 99212 - Lower codes 99211 - The lowest code we’ll use When reviewing the distribution of our office visit coding, we should expect to see a bell curve, with the majority of billed visits falling within the 992x3 to 992x4 range. Time vs. MDM As discussed, E&M coding is more complex and requires strict documentation of the exam. When using E&M codes, you need to decide whether to code based on time spent on the encounter or the level of Medical Decision Making (MDM) utilized. Below is a clear breakdown of the code requirements: New Patients 99202 — Straightforward MDM or Time must meet or exceed 15 minutes of total time spent on the patient’s care on the date of their exam. 99203 — Low level MDM or Time must be at least 30 minutes. 99204 — Moderate level MDM or Time must be at least 45 minutes. 99205 — High level MDM or Time must be at least 60 minutes. Established Patients  99211 — This is a visit that may only require a tech to manage the patient; no doctor interaction is necessary. 99212 — Straightforward MDM or Time must be at least 10 minutes. 99213 — Low level MDM or Time must be at least 20 minutes. 99214 — Moderate level MDM or Time must be at least 30 minutes. 99215 — High level MDM or Time must be at least 40 minutes. Coding by Time Spent When coding based on time spent on the patient’s care on the day of their visit, include the following: 1. Preparation and chart review on the day of the exam 2. Acquiring a history from someone other than the patient 3. Conducting medical history and performing the exam 4. Writing orders for medications, tests, or additional procedures 5. Communicating with other healthcare providers 6. Clinical documentation in the record 7. Interpreting results from diagnostic tests and explaining them 8. Coordinating care beyond the clinic, such as referring the patient to another physician for continuation of care, further evaluation, or surgical consultation Code New Patient Time Requirement Established Patient Time Requirement 99201 Retired — use 99202 99211 Tech visit only, no doctor interaction 99202 At least 15 minutes 99212 At least 10 minutes 99203 At least 30 minutes 99213 At least 20 minutes 99204 At least 45 minutes 99214 At least 30 minutes 99205 At least 60 minutes 99215 At least 40 minutes Take note of the differences in time requirements between new and established patients. Coding by MDM Medical Decision Making (MDM) refers to the complexity involved in establishing a diagnosis and/or selecting a treatment/management strategy. Essentially, the more complex the patient's case, the higher the MDM required to manage it. As discussed earlier, MDM is categorized into four levels of complexity:  1. Straightforward 2. Low 3. Moderate 4. High Factors considered in determining the level of MDM include: 1. The number and complexity of presented problems 2. The amount and complexity of data reviewed 3. The overall patient risk The E/M Codes: (The fourth digit denotes New or Established patient. 0 for new, 1 for established) 99201 has been retired — 99211 is a tech-only visit Straightforward MDM — 99202 (new) and 99212 (established) ○ One self-limited or minor problem with minimal to no complexity of data to be reviewed and analyzed, and minimal risk of morbidity from additional diagnostic testing or treatment. Example: A 16-year-old female presents with acute redness and irritation in both eyes due to allergies to her new cat. Her condition has improved, and her eyes feel much more comfortable. We instruct her to finish her drops and continue with OTC allergy medications and return as needed. ○ Exam: 99212 ○ Assessment: Acute Allergic Conjunctivitis - H10.13 ○ Plan: Continue meds, RTC PRN The 99212 is a good code for "resolving acute ocular problem" follow-up. Low Level MDM — 99203, 99213 ○ Two or more self-limited or minor problems or one stable chronic illness, or one acute, uncomplicated illness or injury with limited complexity of data to be reviewed and analyzed, and low risk of morbidity from additional diagnostic testing or treatment. Example: A healthy 26-year-old female presents with acute redness and irritation in both eyes after adopting a new cat named Dwight D. Eisenmeower. Significant conjunctival hyperemia with eyelid papillae is observed. We recommend an over-the-counter oral allergy medication and prescribe a mild ocular steroid for use twice daily for 10 days. We also discuss the option of renaming the cat. ○ Exam: 99203 ○ Assessment: Acute Allergic Conjunctivitis - H10.13 ○ Plan: Oral allergy, PO, qd with topical steroid OU, BID x 10 days, then taper to QD x 4 days, RTC in 1 week.  The 99203 and 99213 are often used codes for new and acute office visits for primary care physicians. Presenting problems are typically of mild to moderate severity. Moderate Level MDM — 99204, 99214 ○ One or more chronic illnesses with exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms; or one acute complicated injury with moderate complexity of data to be reviewed and analyzed, and moderate risk of morbidity from additional diagnostic testing or treatment. Example: An established 66-year-old diabetic male presents with reduced acuity and increased glare. He reports fair control of his blood sugar with an HbA1c of 6.9. We find moderate 2+ nuclear sclerosis with vitreous syneresis. The retinas are clear of hemorrhaging. We discuss maintaining glucose control and updating the glasses prescription versus referring him for a cataract surgery consult. ○ Exam: 99214 ○ Assessment: Diabetes without complications - E11.9, Bilateral nuclear sclerosis - H25.13, Other vitreous opacities - H43.393 ○ Plan: Monitor progressing cataracts and vitreous degeneration, discuss diabetes management, discuss surgical referral options, patient has decided to wait. The 99214 is a popular code used for billing new comprehensive patients in the office of physicians. Presenting problems are typically of moderate to high severity. High Level MDM — 99205, 99215 ○ One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or one acute or chronic illness or injury that poses a threat to life or bodily function with extensive and significant complexity of data to be reviewed and analyzed, and high risk of morbidity from additional diagnostic testing or treatment. It is extremely difficult to justify using the highest complexity exam code. This is the “wheelhouse” code. Use this code sparingly and only for very complex cases. Good Cheat Sheet: AMA CPT Revised MDM Grid Which Exam Code Should I Use? Consider the documentation in the chart: What level of E/M service or eye code service does it meet? If your documentation meets the requirements for both an Eye Code and its E/M counterpart to the same degree, you can use either one. Routine vs. Medical Care Routine wellness eye care includes the diagnosis and management of refractive-based vision problems where glasses and/or contact lenses are the treatment, as well as screening for medical eye issues. Vision plans generally cover routine wellness care. Medical eye care involves the assessment and management of medical conditions and can be billed to medical insurance plans. This might include topical medication for an acute ocular issue or managing a progressive eye problem. Treatment options can vary significantly. As practitioners and billers, we choose which plan to bill based on the patient’s presenting complaints, their diagnoses, and how we will manage those diagnoses. Patients often consider their vision plan as "eye insurance" and assume it covers all eye-related care. It is our job to help them understand what their plans cover and do not cover. Patients also have a financial interest in using their vision plan as it usually involves a lower copay for their visit. Examples: Consider a few examples to illustrate how management options can vary: Example 1 A 46-year-old new patient presents to the office saying she needs glasses because she can't see things closer up. After a thorough examination, she is found to have hyperopia with presbyopia. She is prescribed glasses for full-time wear and is counseled on her expectations and prognosis. Her ocular health is otherwise unremarkable. Option 1: Routine Code Routine eye examination, including refraction, new patient = 92004 Assessment: Bilateral hyperopia (H52.03), presbyopia (H52.4) Plan: Dispense prescription to be worn full-time, return to clinic (RTC) in 12 months to reassess vision Option 2: Ophthalmological Code Comprehensive ophthalmic exam, new patient = 92004 Determination of refractive state = 92015 Assessment: Bilateral hyperopia (H52.03), presbyopia (H52.4) Plan: Dispense prescription to be worn full-time, RTC in 12 months to reassess vision Example 2 A 46-year-old new patient presents to the office saying she needs new glasses because she can't see things close up or far away as well as when she first got her current prescription last year. After a thorough examination, she is found to have posterior subcapsular cataracts (PSC) in both eyes, as well as hyperopia, astigmatism, and presbyopia. She is prescribed glasses for full-time wear. We spend five to ten minutes explaining what posterior subcapsular cataracts are, how they are affecting her best corrected vision, and counseling her on the expected progression. We also discuss her family history of cataract surgery at a relatively young age. Option 1: Routine Code Routine eye examination including refraction, new patient = 92004 Assessment: Hyperopia (H52.03), Presbyopia (H52.4), PSC (H25.043) Plan: Dispense prescription to be worn full-time, monitor cataracts OU, counsel patient on nature and expected course of progression, RTC in 12 months to reassess vision Option 2: Medical Code Comprehensive ophthalmic exam, new patient = 92004 Determination of refractive state = 92015 Assessment: PSC (H25.043) (no refractive codes on medical claims) Plan: Monitor cataracts OU, counsel patient on nature and expected course of progression, order refraction to determine best acuity through PSC, dispense prescription to be worn full-time, RTC in 12 months to reassess vision Option 3: Medical Code (Extended Visit) New patient office or other outpatient visit, 30-44 minutes = 99203 Determination of refractive state = 92015 Assessment: PSC (H25.043) (no refractive codes on medical claims) Plan: Monitor cataracts OU, counsel patient on nature and expected course of progression, order refraction to determine best acuity through PSC, dispense prescription to be worn full-time, RTC in 12 months to reassess vision As shown in Example 2, there are several options for managing the patient from an insurance perspective. If the patient has a vision plan and expects it to cover all eye care, including glasses, Option 1 allows you to bill the routine exam while considering the cataracts as incidental findings. Alternatively, you can use Option 2 or 3 if you decide that the cataracts are the primary issue and need to be managed as a medical condition. Patient Communication If the patient insists on using their wellness benefit for a routine exam despite the presence of medical issues, you must navigate this carefully. Decide if the principle of billing the correct payer is worth the risk of potentially losing the patient. You can opt for using the vision plan for the initial visit (Option 1) and then transition to billing their medical insurance for follow-up visits related to their cataracts. Incidental Medical Findings When incidental medical findings arise, such as early cataracts or mild dry eye, consider whether it’s appropriate to bill the exam to medical insurance. Even if the initial visit is for glasses, if significant medical issues are discovered, it may be necessary to adjust billing practices. Refractions are part of the diagnostic process and should be interpreted in the context of the patient’s overall ocular health. It’s essential to perform refractions not just to prescribe glasses but to gauge the severity of any underlying medical conditions. Summary Use refractions as part of the broader examination to understand the patient’s visual system. When presenting findings, be transparent with patients about the implications for billing and insurance. Balance the need for appropriate compensation with patient satisfaction and financial concerns. Therefore, when submitting your claim to the medical insurer, the 92015 code should be tied to the medical condition, not a refractive one. 92004 - E11.9 (Type 2 diabetes mellitus without complications) 92015 - E11.9 In your plan, you need to state the reason for performing the refraction. In other words, you need to define the medical necessity: "ORDER REFRACTION TO DETERMINE PATIENT'S BEST CORRECTED ACUITY AS IT RELATES TO (THE PRIMARY DIAGNOSIS)." Bill for your time and expertise In general, if you perform a refraction, bill for it. It’s a skill that takes time, money, and effort to learn and master. Some insurers allow up to $40 for a refraction, independent of, and on top of, the exam fee. Don’t leave money on the table for work that you did and deserve to be paid for. But remember, you must be consistent and charge everyone, with or without insurance, the same fee for the same work. You should inform your Medicare patients that their refraction is not covered and they will be responsible for payment. Pro Tip: Send the 92015 to Medicare. If you don't, you risk the patient being upset if they pay you $40 (or whatever you charge for the 92015) while Medicare and their supplement claim they don't owe anything. Bottom Line: Your patient wants their refractive data to purchase glasses. You need that data to determine if there are any organic problems affecting their best corrected visual acuity.