#18: Avoiding Coding and Billing Disasters

[Richard Pagan]

Richard,
Reason for testing can certainly be included in the I&R, but that alone does not remove the need to have it in the medical record as well. An interpretive report is designed to be duplicative as it is part of a special ophthalmic procedure and must meet those requirements as per CPT definition.

~John

just wondering if, in your opinion, the above example would/could qualify as an example of how insurance companies might recoup fines/penalties. If it is then there is something seriously wrong with that process. I'd call you a criminal if you walked in and said "well you listed the reason for the test in the I and R, but you did not duplicate that reason in the record", and then attempt to collect money from me for services rendered. Thats gratuitous abuse IMO.

[John Rumpakis]

just wondering if, in your opinion, the above example would/could qualify as an example of how insurance companies might recoup fines/penalties. If it is then there is something seriously wrong with that process. I'd call you a criminal if you walked in and said "well you listed the reason for the test in the I and R, but you did not duplicate that reason in the record", and then attempt to collect money from me for services rendered. Thats gratuitous abuse IMO.

Richard,
The order for the test must come chronologically before the test is performed, thus before the I&R is created. The reason for the test is included in the order.

~John

[Lisa Heuer]

Regarding I&R for visual field testing, if you complete a proper and thorough I&R report, do you need to repeat any of those notes on the printout from the instrument? Out of habit and convenience, I still jot a few notes and my signature on the printout, but I'm thinking that this is redundant and unnecessary, especially since those on EMR would be importing the result into the record without making written notes. The same question could apply to printed reports from OCT, topography, etc. Those of you who are still using paper records, what do you do? (We are moving to EMR later this year...)

[David Tabak]

David,
I have never heard that "best practices" will use the 99XX4 the most. That would really concern me because while a 99214 is an easily met standard (the equivalent of a 99203), a 99204 is very difficult for us to meet. Secondly, when you say you always bill a 992X4 assuming you treat the patient also worries me. Each patient, must be individually assessed and coded based upon what you did with that patient. Naturally you would have a much wider distribution of codes you used as not every patient would be scored exactly the same.

John

Sorry, I made a mistake.We use 99214 a lot --we rarely use 99204. Here is my requirements for using a 99214:
Any of the below qualify me to use a 99214, in my opinion...

1)If the patient has a new complaint with the potential for sig. morbidity if untreated or misdiagnosed
2)If the patient has 3 or more old problems
3)If the patient has a new problem that requires a prescription (this is the classic "hot/red eye")
4) If they have 3 stable problems that require medication refills
5) One stable problem one inadequately controlled problem that requires med. refills or adjustments

Dave Tabak

[Anonymous Post Bot]

"I understand a vision exam only covers a screening for health issues and a new prescription if needed. A medical exam includes diagnosis and management of all range of medical issues.

Can a patient you've never seen before choose which exam they do? As many other doctor's do, I work in CP with a nice big sign showing my vision exam price. We tell all patients, and have forms that the pt signs as modified by suggestions on this forum,that medical exams cost more than the vision exam.

So a pt comes in, "wants new glasses", denies knowledge of cataracts or mac deg. BCVA is 20/50.

This pt has a medical insurance that you can't get on and the patient must go see a provider on the panel to use the medical insurance. You find catarcts, but since pt refuses to pay more than the posted vision exam fee, how much detail are you supposed to give the pt about their medical condition? 'You have cataracts but need a medical exam to check how m bad they are.'

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

[Steven Nelson]

"I understand a vision exam only covers a screening for health issues and a new prescription if needed. A medical exam includes diagnosis and management of all range of medical issues.

Can a patient you've never seen before choose which exam they do? As many other doctor's do, I work in CP with a nice big sign showing my vision exam price. We tell all patients, and have forms that the pt signs as modified by suggestions on this forum,that medical exams cost more than the vision exam.

So a pt comes in, "wants new glasses", denies knowledge of cataracts or mac deg. BCVA is 20/50.

This pt has a medical insurance that you can't get on and the patient must go see a provider on the panel to use the medical insurance. You find catarcts, but since pt refuses to pay more than the posted vision exam fee, how much detail are you supposed to give the pt about their medical condition? 'You have cataracts but need a medical exam to check how m bad they are.'

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

If you're telling them at checkout, that's your bad and you eat that extra MDM for what BETTER NOT BE A $49 EYE EXAM! If it is, I will find you.

You HAVE to clear these things up BEFORE you ever see them. Find out what insurances they have, both medical and vision. If you're not on their medical, then you need to decide UP FRONT whether you're going to charge them for a medical visit should that scenario present itself or are you going to pretend those medical issues aren't there and bill as a wellness visit on a patient that clearly isn't "well" and inform the patient accordingly so that they have the option of saying "no thank you".

Either way, if you're not figuring this out until the patient has been seen, you're doing it wrong. Implement better check in protocols. Tomorrow would be good.

[Richard Pagan]

a "routine exam" is not something you choose, like on a menu. It really is just one of many possible outcomes. That being true they need to know in advance if they are willing to risk having to pay higher fees, because you just dont know (and they sure don't know) if its routine or not until you perform the exam. If they dont want to risk it, and demand that they just have the "regular exam" (whatever that is ), we decline to see them.

[Steven Nelson]

a "routine exam" is not something you choose, like on a menu. It really is just one of many possible outcomes.

Love that

[Mike Sandy]

Or are you obligated to tell the patient how severe they are and when you think surgery is needed, all at the cheaper vision exam price?"

If you raise your routine wellness exam fee closer to your medical fee, the sting of doing MDM for wellness pay hurts less financially and emotionally. I think Dr. Pagan's exam fees are the same.

[Anonymous Post Bot]

"I knew you guys would chime in like that.

But the patient didn't want a medical exam, and it's been said here that the pt has the final say.

I'd really like to know what Dr. Hom and especially Dr. Rumpakis think of this."

[Paul Farkas]

ODwire.org Radio/ Podcast hopes to have Dr Richard Hom interviewed shortly. The interest in having a billing and coding expert share information speaks for itself.

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[Neil Speer]

"Order fundus photography" is now "order fundus imaging with associated interpretation and report for documentation of medical condition and future comparison" - similar change for anterior photography.

Would it be acceptable to print the above order out on a small piece of paper and physically attach it to the record rather than hand write it out (I still use paper records)?

[Steven Nelson]

Would it be acceptable to print the above order out on a small piece of paper and physically attach it to the record rather than hand write it out (I still use paper records)?

Printed or not, it doesn't matter. What needs to be there is somewhere in the plan it needs to reflect that you ordered photos and why and there needs to be attached somewhere a separate interpretation and report of the photos. Somewhere in that report needs to have comparative data. Whether it's printed or hand-written really doesn't matter from an audit perspective.

My personal take, and personal take is ALL this is, is that the more professional and polished it looks, the better you look to anyone looking at your stuff. That's true whether it's an auditor, a patient, another OD or an OMD you're referring to. That may very well be my OWN optometric insecurity complex coming out, but that's how I approach things like this.

[Neil Speer]

Printed or not, it doesn't matter. What needs to be there is somewhere in the plan it needs to reflect that you ordered photos and why and there needs to be attached somewhere a separate interpretation and report of the photos. Somewhere in that report needs to have comparative data. Whether it's printed or hand-written really doesn't matter from an audit perspective.

My personal take, and personal take is ALL this is, is that the more professional and polished it looks, the better you look to anyone looking at your stuff. That's true whether it's an auditor, a patient, another OD or an OMD you're referring to. That may very well be my OWN optometric insecurity complex coming out, but that's how I approach things like this.

My digital camera software has a place for interpretation and comparative data for each image, so, I'm assuming that it's sufficient to record findings within the software, not the written paper record.

One more important question:
If I see a new patient, obtain a digital retinal photo during pretest, and identify an abnormality (say, diabetic retinopathy) once the image is reviewed with the patient (during the initial visit), is it OK to bill the insurance company for the photo, despite the fact that the patient was not resheduled to come back in on another day for a photo of the pathology? In other words, can a "screening" retinal photo become a billable photo to document pathology?

[Richard_Hom]

My digital camera software has a place for interpretation and comparative data for each image, so, I'm assuming that it's sufficient to record findings within the software, not the written paper record.

One more important question:
If I see a new patient, obtain a digital retinal photo during pretest, and identify an abnormality (say, diabetic retinopathy) once the image is reviewed with the patient (during the initial visit), is it OK to bill the insurance company for the photo, despite the fact that the patient was not resheduled to come back in on another day for a photo of the pathology? In other words, can a "screening" retinal photo become a billable photo to document pathology?

The difference between an "ordered" photograph pursuant to a retinal eye examination and a condition must be contrasted with a "screening" photograph that is serendipitous in circumstance. The former is likely to be coverable and the latter is questionable.

[Richard Pagan]

One more important question:
If I see a new patient, obtain a digital retinal photo during pretest, and identify an abnormality (say, diabetic retinopathy) once the image is reviewed with the patient (during the initial visit), is it OK to bill the insurance company for the photo, despite the fact that the patient was not resheduled to come back in on another day for a photo of the pathology? In other words, can a "screening" retinal photo become a billable photo to document pathology?

supposedly there are some exceptions but I'd say absolutely not, under any circumstance. Had you looked first and then talked with the pt and said I'd like to take photo (an order) of something that's in your eye, then you could bill it, but even then only if its a valid concern for which the photo can help care for the pt.

[Eric Newberry]

supposedly there are some exceptions but I'd say absolutely not, under any circumstance. Had you looked first and then talked with the pt and said I'd like to take photo (an order) of something that's in your eye, then you could bill it, but even then only if its a valid concern for which the photo can help care for the pt.

I definitely agree with Richard, but how does an outsider (i.e. auditor) know what came first. The screening photo or the ordered photo?

[Richard_Hom]

I definitely agree with Richard, but how does an outsider (i.e. auditor) know what came first. The screening photo or the ordered photo?

Probably it is difficult to discern whether the photography was subsequent to a retinal examination. However, many EHR's time stamp various points in an examination and if a situation were to arise it is possible to tell whether the retinal examination was done before the photograph or not.

In all likelihood, if photographs are done routinely, it would be difficult to prove that it a consequence of an abnormal finding. The trouble occurs when there is no abnormal finding and it is coded to think that there is something coverable. This is highly debatable since a lack of an abnormality means there is no medical necessity even if there is a history of a systemic problem.

[Eric Newberry]

Probably it is difficult to discern whether the photography was subsequent to a retinal examination. However, many EHR's time stamp various points in an examination and if a situation were to arise it is possible to tell whether the retinal examination was done before the photograph or not.

In all likelihood, if photographs are done routinely, it would be difficult to prove that it a consequence of an abnormal finding. The trouble occurs when there is no abnormal finding and it is coded to think that there is something coverable. This is highly debatable since a lack of an abnormality means there is no medical necessity even if there is a history of a systemic problem.

I struggle with this chicken and the egg concept daily, especially with retinal nevi. We take and charge for screening retinal photos routinely. They are the first thing on my screen when I go into the room. I like to get a gross idea of retinal health before I begin refracting. I also quickly review corneal topography on each patient before retraction. I feel this saves me significant time in some cases. I feel it's silly if there is an obvious retinal nevi that I feel needs following, I have to then "order" another photo to be taken at end of exam just to meet insurance requirements. We do it, but its crazy!