medical records coding: choosing 92000 codes accurately charles b. brownlow, od, faao...
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Medical Records Coding:Choosing 92000 Codes
Accurately
Charles B. Brownlow, OD, FAAO cbrownlow@revolutionehr.com
January 10, 2013
• 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”
Plan of Action for this Webinar
Series
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– askthecodingexperts@excelod.com– 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 ServicesNote: 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. History4. 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 fields6. 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’sDefinition 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
• 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
Procrastination is passé
Questions?
cbrownlow@revolutionehr.com
Additional webinars in this series will be based on your feedback and on current medical records
challenges facing eye care providers
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