BILLING AND CODING - Texas Optometric Association

BILLING AND CODING
Description:
In today’s optometric practice, insurance is a major source of the practice’s income including
both government and private company coverages. Each year it seems that participating provider
payments are reduced or stringent stipulations are implemented that require certain components
be included in the exam in order to be able to code and bill for the services provided.
Companies, whose sole function is to audit and recoup monies paid to participating providers,
have struck fear in the hearts of more than one optometric practice when they receive the letter or
call that they are to undergo an audit. Coding and billing is like completing your tax return. You
are entitled to every deduction you are qualified for (billing appropriately for every penny for
services provided), but do not cheat the tax man (do not over code nor short change yourself by
under coding). You will learn in this course the detailed criteria for choosing the proper code
and how to build the proper code so that you can receive the payment to which you are entitled
while ensuring compliancy and being audit proof. It is one thing to work for “free” but, to work,
get paid, spend the money, and then have to give it back makes for a bad day!
Learning Objectives:
1.
2.
3.
4.
5.
6.
You will learn what criteria goes into choosing the proper code.
You will learn who is responsible for getting a complete patient history.
You will learn the components and levels of a complete patient history.
You will learn the components and levels of an exam.
You will learn the four levels of complexity of decision making.
You will also learn what is and is not your responsibility.
Technical__________
General Knowledge____x____
Level of Instruction: Basic:_x___
Intermediate:_____
Introduction
Advanced:_____
2 min.
Staff play a major role in the documentation for payment by insurance companies. It is very
important to do your part and do it correctly or the doctor has to go back and do it if he wants to
be paid and the money not be requested back from him in an audit.
I.
WHAT GOES INTO CHOOSING THE PROPER CODE?
3 min.
Four things that determine which level of service to bill.
A. Extent of History Taking
B. Extent of Examination
C. Complexity of Medical Decision Making
D. Determine which Procedure Code
II.
HISTORY IS YOUR RESPONSIBILITY
5 min.
A. Of these four elements above history is the one that is the staff’s responsibility.
B. You must have a complete medical history on each patient. This should be completed
on the first visit and updated on each visit afterward.
C. On visits after the initial visit on the exam form it should reference the date of the
full history taken and noted any changes or no changes at this time and the doctor
must initial.
D. This Medical History should be completed on every patient whether they have
insurance or not and no matter what age they are. You should be consistent with your
history taking regardless of what kind of patient it is.
E. If it is a two sided form make sure the back is completed. If every box is not checked
yes or no the form is not complete and you will not receive credit for it.
F. You need a complete history on every patient you bill a 99XXX or 92XXX code.
III.
WHAT DOES A COMPLETE HISTORY CONSIST OF?
20 min.
A. New/Established Patient
1) New
a) Never been to your office
b) It has been at least 3 years and 1 day since last visit
c) Bill new patient procedure code
2) Established
a) if the patient has been to your office in the last three years
b) Bill est. patient procedure code
B. Chief Complaint (CC)
1) A fragment of a sentence of why the patient is in your office.
2) Examples of Chief Complaint (CC): blurry vision, decrease in visual
acuity, eyes itch, eyes watering, eye pain
C. History of Present Illness (HPI)
1) Describe in detail each component of the patient’s chief complaint.
2) Example of History of Present Illness (HPI):
Location…..R, L, both eyes, upper lids, lower lids, etc
Quality…….Characteristics or attributes of the condition
Severity……Mild, Moderate, Severe
Duration…...Length of time that the condition has been present
Timing……..Getting worse, getting better
Context…….The context in which the present illness occurs (i.e.,
“in the morning”, when I bend over”, “only at night”, etc.)
Modifiers…..Conditions that affect the present illness (i.e.,
Tylenol, ice pack, rewetting drops, etc.)
Symptoms….Any other symptoms related to this illness
D. Family History
1) This needs to be completed on every patient.
E. Past History
1) This needs to be completed on the first visit to office and reviewed for
changes on each visit.
F. Social History
1) Use of tobacco products
2) Illegal drugs or alcohol
3) Exposure to sexually transmitted diseases
4) Occupational exposure to chemicals
5) Most offices do not like to ask these kinds of questions but the
insurance companies require these answered for patients over 13 yrs old.
G. Review of Systems
1) There are 14 Systems of the Body and Optometry is required to get 11
out of 14 of the Systems.
2) Make sure you have a good checklist.
IV. LEVELS OF HISTORY
10 min.
There are four levels of history. When working with a new patient 1/3 of payment is for
history and on an established it is 1/2 of payment. Tip: Do a comprehensive history on all
patients then you know you have it.
1. Problem Focused History (PFH)
Chief Complaint/1-3 HPI (History of Present Illness)
2. Expanded Problem Focused History (EPF)
Chief Complaint/1-3 HPI/Ocular ROS
3. Detailed History (DH)
Chief Complaint/4 HPI/Ocular ROS/ROS-2/1 of 3 Past, Family, or Social
History
4. Comprehensive History (CH)
Chief Complaint/4 HPI/Ocular ROS/ROS-10/3 of 3 Past, Family and
Social History (New Patient) or 2 of 3 (Established Patient)
V.
VI.
VII.
EYE EXAM ELEMENTS
10 min.
1. Elements of Eye Exam
 VA/CVF/Pupils & Iris/Adnexa
 Bulbar & Palp Conjunctiva
 EOM
 SLE: Cornea/Lens/AC
 IOP/Optic Nerve/Posterior Segment
 Neurologic: Orientation (Time/Place/Person)
 Psychiatric: Mood & Affect (Depression/Anxiety/Agitation)
2. Subgroups
 Eyelids/Adnexa
 Anterior Segment Disease
 Posterior Segment Disease
 Ocular Motility
LEVELS OF EXAMINATION
There are four levels of examination and they are as follows:
1. Problem Focused Exam (PFE)
Limited Exam/1-5 Elements
2. Expanded Problem Focused Exam (EPF)
Limited Exam/6 Elements
3. Detailed Exam (DE)
Extended Exam/9 Elements
4. Comprehensive Exam (CE)
Complete Single System Exam/All Elements
10 min.
MEDICAL DECISION MAKING
There are four levels of decision making and they are as follows:
1. Straightforward (SF)
#DX/RX Options-Minimal/Risk-Minimal
No brain power
2. Low Complexity (LC)
#DX/RX Options-Limited/Data-Limited/Risk-Low
This is Auto-Pilot-not a whole lot of effort-98% of the time
10 min.
3. Moderate Complexity (MC)
#DX/RX Options-Multiple/Data-Moderate/Risk-Moderate
Start a treatment-Change a treatment-Decision for surgery-Outside
consult or referral
4. High Complexity (HC)
#DX/RX Options-Extensive/Data-Extensive/Risk-High
Wheels of the bus are coming off at 70 MPH.
Threatens loss of eye sight
VIII.
IX.
E/M CODING-OFFICE VISITS
1. New Patient (3 of 3)
99201- (1) PFH/(1) PFE/(1) SF
99202-(2) EFH/(2) EPF/(1) SF
99203-(3) DH/(3) DE/(2) LC
99204-(4) CH/(4) CE/(3) MC
99205-(4) CD/(4) CE/(4) HC
2. Established Patient (2of 3)
99211-Minimal
99212-(1) PFH/(1) PFE/(1) SF
99213-(2) EFH(2) /EPF/(2) LC
99214-(3) DH/(3) DE/(3) MC
99215-(4) CH/(4) CE/(4) HC
20 min.
EYE CODES
10 min.
A. 92004/92014
Comprehensive Ophthalmological Service
1. Need not be performed at one session
2. 8 or more of the Eye Elements documented
3. Includes history, medical observation, external &
ophthalmoscopic examinations, gross visual fields,
sensorimotor examination
4. Often includes biomicroscopy, examination with cycloplegia or mydriasis and
tonometry
5. May include but not required to dilate but some years you had to do a dilation to
bill this code. You need to reference the code book each year to verify wording.
6. Always includes initiation of diagnosis and treatment programs
7. This year the wording states as indicated includes the prescription of medication,
and arranging for special ophthalmological diagnositic or treatment services,
consultations, laboratory procedures and radiological services. Not including
over the counter treatments. Some years you had to do one of the above to bill
this code but at the current time it is as the doctor indicates need. There are a few
states that have a Local Determination that states glasses can be considered a
prescription of medication and Texas is one of those states.
B. 92002/92012
Intermediate Ophthalmological Service
1. Includes 7 or less of the Eye Elements
2. Evaluation of new or existing condition, complicated with a new diagnostic or
management problem, not necessarily relating to the primary diagnosis
3. Includes history, medical observation, external & adnexa, & other diagnostic
Procedures as indicated/May include use of mydriasis for ophthalmoscopy
C. 92015
Refraction
1. Billed in addition to 99XXX/92XXX
2. Non-covered service on most insurances
3. Charge only for “RX-able” refractions
4. Do not forget to charge for the final refraction when changing spectacles
in a post-operative cataract patient
D. S0620/S0621 Routine Comprehensive Eye Exam including Refraction
1. The only code for routine/refractive eye exam
2. Can be used for private pay patients exams
3. Billed at a different fee than a medical exam
X.
WHAT IS NOT YOUR RESPONSIBILITY?
5 min.
A. It is not your responsibility to choose a procedure code or a diagnosis code at check
out unless you are a certified coder.
B. You are putting your doctor under a great liability when you make decisions you are
not qualified to make.
C. Diagnosis codes are now broken down to very specific for diseases of the eye so this
needs to be returned to the doctor so he can choose the appropriate diagnosis that will
match his exam notes. It will not pass an audit if these two things