Medical Records Coding: Choosing Codes Accurately Charles B. Brownlow, OD, FAAO 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 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, 9 th 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, –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 –Monthly webinars, usually 2 nd /4 th 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, (new)/92012(established) Comprehensive, (new)/92014 (established) –Evaluation and Management Services New patient services, Established patient services, 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

Evaluation and Management Services (99000 codes) Visit codes are chosen by first ‘grading’ the level of the case history, physical examination, and medical decision making recorded in the patient’s chart Case history has four components critical to patient care, medical records, and choice of codes –Chief complaint/reason for visit –History of present illness –Review of systems –Past, family, social history

Grading Each Component of Case History Reason for Visit—No grade, but no record is complete without a reason! –Chief Complaint, presenting problem, physician directed return to office, symptom, etc. –Reason for visit must be customized to each visit History of Present Illness, HPI (questions to learn the details relative to the reason for visit) Review of systems (asking questions related to any of the 14 organ systems germane to this day’s visit Past/family/social history (questions about patient’s health and ocular history, family health and ocular history, and patient’s social history)

Grading Case History Once the ‘grades’ for the HPI, ROS and PFSH are determined, the grade for the Case History is determined based on the lowest of those three. Note: In the chart below, the history would be graded ‘expanded problem focused’ due to the ‘brief’ HPI. HistoryReason for Visit HPIROSPFSH Problem FocusedRequiredBriefN/A Expanded Problem Focused RequiredBriefProblem Pertinent N/A DetailedRequiredExtended Pertinent ComprehensiveRequiredExtendedComplete

Grading Case History Note: In the chart below, the history would be graded ‘Detailed’ due to the ‘extended’ HPI and ROS. HistoryReason for Visit HPIROSPFSH Problem FocusedRequiredBriefN/A Expanded Problem Focused RequiredBriefProblem Pertinent N/A DetailedRequiredExtended Pertinent ComprehensiveRequiredExtendedComplete

Key Reminders… Auditors may reject a claim if they feel the reason for visit does not support the level of code chosen, even if all the components of the record support the choice. Doctors must follow the rules and be ready to defend –Decisions relative to the case history and physical examination –The diagnoses and management options –The content of their medical record and –Their choice of CPT and ICD codes

The Physical Examination--Eyes Doctors provide the examination services they believe each patient needs –The grade for the physical exam results from counting which of the following exam elements were completed: Visual Acuities, Visual Fields (confrontation), Ocular adnexae (including lac. Glands, lac. Drainage, orbits, preauricular nodes), pupils and irises, motility/versions, corneas, anterior chambers (depth, angles, cells, flare), Lenses (clarity, capsules, cortex, nucleus), Bulbar and palpebral conjunctiva, Intraocular pressures, dilated ophthalmoscopy (discs and peripheral retina), brief assessment of mental status (orientation to time/place/person and mood/affect)

Grading the Physical Examination The examination is graded one of four levels: –Problem focused, 1-5 ophth. elements recorded –Expanded problem focused, 6-8 ophth. elements recorded –Detailed, 9 or more ophth. or psych. elements recorded –Comprehensive, all 12 ophthalmic and both psychiatric elements recorded Note: eye doctors frequently do fairly detailed case histories and physical examinations, especially with new patients, due to the relationship of systemic medical conditions and eye problems

Medical Decision Making The final component of the medical record, medical decision making, includes information related to – The number of diagnoses and management options related to the visit –The amount and complexity of data considered during the visit and resulting from the visit, and – The level of risk represented by the diagnoses, the diagnostic procedures, the treatments related to the visit The medical decision making is graded based on the highest two of the three components Note: Since ‘amount and complexity of data’ is very subjective and hard to measure, we recommend you grade the medical decision making according to the lower grade for the number of diagnosis and management options and the level of risk

Grading Decision Making Grading the number of diagnoses and management options is a matter of adding them up and choosing Grading the risk is done by referring to a chart in the Documentation Guidelines for the Evaluation and Management Services In the example below, the grade would be ‘straightforward’ Complexity of Decision Making Number of Dx/management options Amount/complexity of data Risk StraightforwardMinimal *Minimal or noneMinimal Low complexityLimited Low Moderate complexity MultipleModerate High ComplexityExtensive High *

Grading Decision Making In the example below, the grade would be ‘Moderate complexity’, based on the moderate risk, the lower of the two elements, number of Dx/man. options and risk. Complexity of Decision Making Number of Dx/management options Amount/complexity of data Risk StraightforwardMinimalMinimal or noneMinimal Low complexityLimited Low Moderate complexity MultipleModerateModerate * High ComplexityExtensive *ExtensiveHigh

Choosing Series Office Visit Codes Office visit codes are chosen based on the level of the history, the physical examination, and the medical decision making For new patients, the choice is made by grading to the lowest of the three elements For established patients, the choice is made by grading to the ‘middle’ of the three elements so that at least two are at or above that level

99000 Codes, new patient, (requires 3 of 3 criteria) Leve l CodeHistoryExamDecision makingTime in minutes Problem focused Straightforward Expanded problem focused Straightforward Detailed Low Complexity Comprehensive Moderate Complexity Comprehensive High Complexity60

Choosing a New Patient Code Codes, new patient, (requires 3 of 3 criteria) LevelCodeHistoryExamDecision makingTime in minutes Problem focused Straightforward Expanded problem focused Straightforward Detailed *DetailedLow Complexity ComprehensiveComprehensive *Moderate Complexity Comprehensive High Complexity *60 In the example below, the correct code would be 99203

Choosing a New Patient Code Codes, new patient, (requires 3 of 3 criteria) Leve l CodeHistoryExamDecision makingTime in minutes Problem focused *Problem focusedStraightforward Expanded problem focused Straightforward Detailed Low Complexity ComprehensiveComprehensive *Moderate Complexity Comprehensive High Complexity *60 In the example below, the correct code would be 99201

Choosing Codes for Established Patients

99000 Codes, established patient, ( requires 2 of 3 criteria) LevelCodeHistoryExamDecision makingTime in minutes Nurse service or doctor supervised service, Problem focused Straightforward Expanded Problem focused Low Complexity Detailed Moderate Complexity Comprehensive High Complexity40

99000 Codes, established patient, (requires 2 of 3 criteria) LevelCodeHistoryExamDecision makingTime in minutes Nurse service or doctor supervised service, Problem focused Straightforward * Expanded Problem focused Low Complexity Detailed * Moderate Complexity Comprehensive High Complexity40 In the example below, we code to the middle of the three elements, meaning two are at or above that level, 99214

99000 Codes, established patient, (requires 2 of 3 criteria) LevelCodeHistoryExamDecision makingTime in minutes Nurse service or doctor supervised service, Problem focused Straightforward * Expanded Problem focused Expanded Problem focused * Low Complexity Detailed * Moderate Complexity Comprehensive High Complexity40 In the example below, we code to the middle of the three elements, meaning two are at or above that level, 99213

Choosing a 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 or 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 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/ 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/ 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 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 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 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 Code CPT definitions are more subjective Documentation Guidelines for the Evaluation and Management Services add more details to the definitions As with all codes, 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 charts/audit) –Develop in-office protocols to ensure consistent record keeping and compliance with payers’ rules Procrastination is passé

Questions? Additional webinars in this series will be based on your feedback and on current medical records challenges facing eye care providers