Series 5 coding Power Point 92010 - Idaho Optometric Physicians

10/29/2010Presented byCharles B. Brownlow, OD, FAAOMedical Records Consultant,Clinical and Practice Advancement GroupAmerican Optometric AssociationAskTheCodingExperts@aoa.orgAOA Medical Records and CodingSeries V“Coding Grand Rounds”HandoutsHandoutsforforThisThisCourseCourse• Emailed to you• Available for download at the AOA website:www.AOA.org/Coding– Grading sheets for the 99000 and 92000codes• Documentation Guidelines for the 99000Codes• Sample Medical Record FormDisclaimers/ConfessionsThis presentation was…1. Current at the time it was prepared2. Drawn from national policies, with linksincluded in the presentation for your use3. Prepared as a tool to assist doctors and staffand is not intended to grant rights or imposeobligations4. Prepared and presented carefully to ensure theinformation is accurate, current and relevantDisclaimers/Confessions, con.• Of course the ultimate responsibility for thecorrect submission of claims and compliancewith provider contracts lies with the provider ofservices, and…• The AOA and its presenters, agents, and staffmake no representation, warranty, or guaranteethat this presentation and/or its contents areerror‐free and will bear no responsibility orliability for the results or consequences of theinformation contained hereinWho is this guy?Dr. Charles Brownlow• Practiced optometry in Weyauwega, Wisconsin• Executive vice president of the WOA 1990‐2008• Currently associate director, WOA• Currently consulting with AOA members through h theThird Party Center and Clinical and PracticeAdvancement Group• Long time volunteer in optometry, having served aspresident of his state association as well as the NorthCentral StatesGoals for this Series• To provide an introduction to and/or a review ofgeneral principles related to medical records andchoices of codes• To introduce attendees to resources available throughAOA for doctors and staff• To provide direct assistance to doctors and staff forquestions related to medical records and coding• To enhance necessary intra office and inter officecommunication/sharing of patient information• To reduce doctor/staff frustration with medicalrecords, coding, claims submission, etc.1

10/29/2010Evaluation and Management Services (99000series codes)• Visit codes are chosen by matching the content ofthe medical record with the details of the definitionsin CPT and the Documentation Guidelines for threekey components*:– Case History– Physical Examination– Medical Decision MakingThe Demographics, Reason for Visit, History ofPresent Illness, and Past/Family/Social History*Note: Time is not used in choosing 99000 codes unless more than half ofdoctor’s face to face time with a patient is spent in counseling/coordination of careGrading the History of Present IllnessGrading the History of Present IllnessThe Review of SystemsGrading the Review of Systems3

10/29/2010Grading Past/Family/Social Historyand Case HistoryPhysical Examination, Part 1Physical Exam, Part 2Grading Physical ExaminationMedical Decision MakingGrading Medical Decision Making4

10/29/2010Grading the Office Visit…Established Patient99000, Evaluation and Management Codes, Established PatientGrade to the level of the second highest of the three components; History,Physical Examination, or Medical Decision MakingLevel Code History Physical Exam Med. Dec.Making1 99211 Nurse or doctor supervised service 52 99212 Prob. Focused Prob. Focused St Forward 10Time inMinutes*Questions?3 99213 Exp. Prob.FocusedExp. Prob.FocusedLow 154 99214 Detailed Detailed Moderate 255 99215 Comp. Comp. High 40Demographics, Reason for Visit, History of PresentIllness, Past/Family/Social History, Second CaseReview of SystemsGrading the Review of SystemsGrading Review of Systems and CaseHistory5

10/29/2010Physical Examination, Part OnePhysical Exam, Part TwoGrading the Physical ExaminationMedical Decision MakingGrading Medical Decision MakingGrading the Office Visit…Established Patient99000, Evaluation and Management Codes, Established PatientGrade to the level of the second highest of the three components; History,Physical Examination, or Medical Decision MakingLevel Code History Physical Exam Med. Dec.Making1 99211 Nurse or doctor supervised service 5Time inMinutes*2 99212 Prob. Focused Prob. Focused St Forward 103 99213 Exp. Prob.FocusedExp. Prob.FocusedLow 154 99214 Detailed Detailed Moderate 255 99215 Comp. Comp. High 406

10/29/2010Choosing A 92000 Code• As with all services, use these codes only when thecontents of the record matches the definitions in CPT• Most visits can be reported using either 99000 or 92000codes• 92000 office visit codes are most frequently used for eyecare visits…invite audits• Must code correctly to– Receive proper reimbursement– Avoid audit problemsObvious Differences Between99000 and 92000 Codes• Requirements for 92000 codes are more generalthan those for the 99000 codes– 92002‐92014 require ‘history’– 99000 series requires certain levels of history of presentillness, review of systems and past/family/social history– 92002‐92014 require external and adnexal exam– 99000 series include specific requirements for adnexae(lids/lac. Glands/drainage/orbits/nodes)Considerations for 92000 vs 99000• About 75% of visits can be billed as a 99000 code ora 92000 code• How to decide?– Higher reimbursement for one or other– Record more clearly supports one or other– Patient’s insurer requires using one set or other– Your in‐office protocol requires 92000 for non medicalservices and 99000 for medical?– Other reasons?General Ophthalmological Servicecodes are…– Designed to report medical eye care visits– May be used to report routine eye careNote: Refraction is a separate service (92015) andis not included in any other code, unlessrequired by contract with payer…92014/92004does not include refraction!CPT Definition for IntermediateOphthalmological Services…92002/92012Note: Current Procedural Terminology( © American MedicalAssociation) is the only accepted source of definitions forthese services.“Intermediate ophthalmological services describes anevaluation of a new or existing condition complicated witha new diagnostic or management problem not necessarilyrelating to the primary diagnosis, including history, generalmedical observation, external ocular and adnexalexamination and other diagnostic procedures as indicated;may include the use of mydriasis forophthalmoscopy…with initiation (or continuation) ofdiagnostic and treatment program.”New (92002) or established patient (92012)Requirements of IntermediateOphthalmological ServicePayers often develop their own interpretations ofthese definitions, but the elements that areclearly included in the CPT definition are:1. A new or existing condition…2. complicated with a new diagnostic or managementproblem not necessarily relating to the primary diagnosis3. History4. General medical observation7

10/29/2010Required Elements for IntermediateOphthalmological Service5. External ocular/adnexal examination6. Other diagnostic procedures as indicated7. Initiation (or continuation) of a diagnostic and treatmentprogramKey: If one (or more) of these elements is missing,the visit cannot be coded as intermediateophthalmological service.CPT Definition for ComprehensiveOphthalmological Service• “Comprehensive ophthalmological services describes ageneral evaluation of the complete visual system. Thecomprehensive services constitute a single service entitybut need not be performed at one session. The serviceincludes history, general medical observation, externaland ophthalmoscopic examinations, gross visual fields andbasic sensorimotor examination. It often includes, asindicated: biomicroscopy, examination with cycloplegia ormydriasis and tonometry. It always includes initiation ofdiagnostic and treatment programs.”• New (92004) or established (92014) patientRequirements of ComprehensiveOphthalmological ServiceAgain, payers often develop their own interpretationsof these definitions, but the elements that arerequired by the CPT definition are:1. General evaluation of the complete visual system2. History3. General medical observation4. External examinationRequirements of ComprehensiveOphthalmological Service5. Ophthalmoscopic examination (with or withoutcycloplegia or mydriasis6. Gross visual fields7. Basic sensorimotor examination8. Initiation of diagnostic and treatment programIf one (or more) of these elements is missing, thevisit cannot be coded as comprehensiveophthalmological service.Initiation of Dx/TxProgram Is Critical• Most frequent target of reviewers/ auditorsof eye care records• Every office must have a clear definitionand understanding of what’s included ineach component of the CPT definition,especially the initiation (continuation) ofdiagnostic and treatment programYour Initiation of Initiation of Dx/TxProgram• Probably will include 15‐20 items, ie:– Return to Office• For recheck• For additional tests– Rx meds– Rx specs– Rx CLs– Refer for Dx/Tx8

10/29/2010Know the Definitions and Comply• All eye care offices report many visits using 92000codes• Many offices are unfamiliar with the CPT definitionsand requirements for those codes• Those offices are very vulnerable to audits byinsurers• Must not use any codes unless familiar with the CPTdefinitions/requirementsCoding Our Visits with 92000 CodesIntermediate Ophthalmological Service (92002/92012)__ 1. A new or existing condition…__ 2. complicated with a new diagnostic or managementproblem not necessarily relating to the primary diagnosis__ 3. History__ 4. General medical observation__ 5. External ocular/adnexal examination__ 6. Other diagnostic procedures as indicated__ 7. Initiation (or continuation) of a diagnostic and treatmentprogramRequirements for 92004/92014Comprehensive Ophthalmological ServiceA general evaluation of the complete visual system…__ 1. History__ 2. General medical observation__ 3. External examination__ 4. Ophthalmoscopic examination (with or without cycloplegiaor mydriasis__ 5. Gross visual fields__ 6. Basic sensorimotor examination__ 7. Initiation of diagnostic and treatment programSurprisingly, each of these visits could have been billed as 92014Both Examples Qualify as 92014• Each of our cases qualified as some level of99000 and alternatively as 92014• More specific requirements might favorchoosing the 99000 codes in some cases• Less stringent, more general requirements,might favor choosing the 92000 codes in othercases• Knowing the rules lets you chooseintentionally and accurately!Projects for Doctors and Staff• Pull ten charts and their route slips or claim forms• Print out PMI grading sheets for the 99000 and the 92000codes codes (available at http://www.aoa.org/x16167.xml)• Utilize grading sheets to– Choose level of 99000 code for each– Use 92000 grading sheets to choose 92000 codes• Consider advantages/disadvantages of each code for eachcase• Decide whether 99000 or 92000 fits each visit bestMore Webinars to Come• Additional webinars in this series will be basedon…– Your requests for specific subjects to cover– Most frequently asked questions received andanswered at askthecodingexperts@aoa.org– New issues that arise to challenge AOA membersrelative to medical records, coding, etc.– Your feedback/suggestions are critical9

10/29/2010AOA Resources Related to CodingWeb Based Resources• Codes for Optometry—Two volumes $125– AOA Order Department, 1‐800‐262‐2210• AMA Current Procedural Terminology, and• AOA Codes for Optometry– ICD‐9 abridged for the eye– Documentation Guidelines– Correct Coding Initiatives from Medicare– HealthCare Common Procedure Coding System(HCPCS) for Coding Materials in Medicare– Companion readable CD, $25• AOA.ReimbursementPlus.com– Subscription based resource, including codinginformation for procedures and diagnoses,accepted combinations of codes, complianceguidelines and reimbursement informationspecific to the insurers with which your office iscontracted– Popular program offered to AOA members atsignificant discountAOACodingToday.comAOACodingToday.com• Online Coding and Reimbursement Tool– Includes info from key national references• Medicare ‐Coverage determinations, RVUs, Correct Coding Initiatives• CPT ‐ Current tProcedural lTerminology• ICD9 ‐ International Classification of Diseases• Special information about codes common to eye care (auditcautions, etc.)• Improves Accuracy and Efficiency of Your Medical Billing, MakingIt Easier to Submit “Clean Claims”$349New AOA Member BenefitNo Cost to AOA Members (June 2010)New and RenewingAOA membersAOA ResourcesAOA Website Sections Provide Information RegardingPrivate Insurers and Governmental Health Programs– Third Party Center http://www.aoa.org/TPC– Clinical & Practice Advancement Grouphttp://www.aoa.org/CPAG• Clinical Practice Guidelines• Frequently Asked Questions• Webinars and other online education for doctors and staff• Articles in AOA NEWS and the Journal of the AOA• AskTheCodingExperts@aoa.org– Email your questions direct to an expert– Include AOA member’s name and state– Paraoptometric Membership ps@aoa.orgNo Office is an Island• Many resources available, but it’s up to you to seekthe answers• Don’t be shy about emailing your questions toAskTheCodingExperts@aoa.org . This is a free service to AOAMembers and their staff.• Watch for additional webinars and other AOAeducational programs on medical records and codingcoming this summer!10

10/29/2010Get ConnectedJoin the Coding & Billing Group onAOA Connect at www.AOAConnect.comwww.AOAConnect.comNew to AOA Connect?•Visit http://connect.aoa.org.•Accept the Terms of Use• Search Coding & Billing•Join the Coding & Billing GroupThank YouQuestions?Askthecodingexperts@aoa.orgAdditional Resources: Order Department 800‐365‐2219www.aoa.org/TPCorders@aoa.orgwww.aoa.org/CPAGps@aoa.orgwww.aoa.org/EHR11