By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement
In the evolving world of ophthalmology, the correct way to go about doing things can change—and this is as true for coding as it is in the exam lane or the operating room. But if your practice observes these 6 best practices, your coding should remain tip-top.
1. Don’t use a colleague’s NPI. When new physicians are awaiting credentialing, there is a misconception that they can see patients under another physician’s National Provider Identifier (NPI), provided that the physician who is already credentialed signs off on the charts. Not true, as this cautionary example shows: A new physician, Dr. D. Howser,* is using the NPI of his seasoned colleague, Dr. J. Kildare.* The apparent increase in Dr. Kildare’s utilization of services put him on auditors’ radar. When the documentation revealed that the exam and other services were not performed by Dr. Kildare, the payer recouped payment for the exams and tests, added a penalty, and began auditing him every 3-6 months.
2. Do keep the physician’s signature secure. You will run into trouble if anybody other than the physician signs the physician’s name on letters, chart notes, operating room progress notes, etc. When auditors reviewed Dr. Kildare’s chart notes, for example, they turned the documentation over to the CMS fraud and abuse unit after noticing that he had two distinct signatures. (A circulating nurse had been signing Dr. Kildare’s name on progress reports.)
3. Don’t “correct” coding for an encounter without getting the physician’s input. Dr. Kildare was being audited on E&M code 99214 for high volume. This surprised him, as he only uses Eye visit codes. It turned out that the biller, without consulting Dr. Kildare, had changed all 92014s to 99214s. Unfortunately, the chart note was not set up to capture the additional documentation that would be required to support that E&M code (i.e., the review of systems; the past, family, and social history; and at least a moderate level of medical decision-making). Take-home point: The physician is ultimately responsible for selecting the CPT and ICD-10 codes. When staff feel the codes are incorrect, they must notify the physician and have a discussion before any change is made. These conversations can be great teaching opportunities.
4. Do participate in payer listservs. Auditors expect your documentation to be in line with the policy that was in place at the time of the patient encounter. The challenge is that each payer frequently updates its policies, and once the policy change has been published the payer has fulfilled its obligation to inform you of the change. To stay current on payers’ latest payment policies, participate in their free listservs. As soon as you learn about a policy change, make sure you share it with all who need to know, including physicians, technicians, scribes, billers, and coders. You also should visit aao.org/lcds to review the Medicare Part B local coverage determinations (LCDs) for each Medicare Administrative Contractor (MAC) that you work with.
5. Don’t apply one payer’s rules or perceived rules to all other payers. Each payer can, and often does, have its own requirements—even among MACs. A commercial payer with several carve-out plans often has rules unique to one of the carve-outs due to negotiations with businesses.
6. Do have a good contact at each payer. Ideally, your relationship with each payer’s representative should be such that he or she would want to become your patient and refer family and friends.
* Drs. Howser and Kildare are fictional, but they’re not the fictional TV doctors that you’re thinking of.
Demonstrate coding competency. Visit aao.org/ocs to learn about the Ophthalmic Coding Specialist (OCS) and OCS Retina (OCSR) exams.
Be audit ready. Use the free web audit resource at aao.org/practice-management/regulatory/audit-toolkit (free benefit for Academy and AAOE members). And go to aao.org/store for the Audit Survival Toolkit webinar (product #01250098U) and the Coding Audit Success Toolkit (product # 120444V).