• What You Didn’t Learn in Medical School About Proper Documentation

    Note: This article incorrectly described the requirements to bill for testing services. Only subsequent ophthalmoscopy CPT 92226 must have a clearly drawn change in pathology. All other tests can be billed when medically necessary.

    Proper documentation isn’t necessarily addressed in medical school. Yet, it’s a critical factor in both getting your claim paid and having to pay back hundreds of thousands of dollars in an audit. In this addition of YO Info, we’ll focus on some of the documentation basics for the various services a physician provides.

    Documentation for Exams

    As an ophthalmologist, you can choose from either E/M or Eye CPT codes. The documentation requirements vary between the two, but the signature requirements for both are the same. An acceptable signature must include the physician’s legible full signature, a legible first initial and last name or a signature above the typed name.

    E/M codes. Although there are seven documentation components for E/M codes, history, exam and medical decision-making entail the key elements. The other four parts — counseling, coordination of care, the nature of presenting problem and time — may also be present. Oftentimes, the “history” component is the weakest part of the documentation, so it’s important to take a good history when medically indicated. CPT codebooks offer the necessary audit tools to determine the appropriate level of E/M code.

    Eye codes. These don’t have nearly the same amount of documentation requirements as E/M codes, and there is no formal audit tool. However, the Academy has developed guidance on how to appropriately document for both intermediate and comprehensive Eye code services.

    Intermediate Eye codes require:

    • Documented evaluation of new or existing conditions complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis;
    • History;
    • General medical observation;
    • External ocular and adnexal examination; or
    • Other diagnostic results as indicated.

    The Intermediate Eye codes may also include the use of mydriasis for ophthalmoscopy.

    Comprehensive Eye codes require:

    • History;
    • General medical observation;
    • External and ophthalmoscopic examinations;
    • Gross visual fields;
    • Basic sensorimotor examination; and
    • Initiation of diagnostic and treatment programs.

    The latter may include prescription of medication, arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services.

    Moreover, the Comprehensive Eye code exam often includes — as indicated — biomicroscopy, exam with cycloplegia or mydriasis and tonometry.

    Testing Services

    Tests not performed by a physician should always be accompanied by an order in the patient’s chart. In addition, medical necessity should be supported by documentation of the patient’s signs and symptoms. Many tests have a payer policy that can help determine what to document for medical necessity. If you are performing a test as a screen for the patient, you should also include the necessary Advance Beneficiary Notice (“ABN”) or waiver forms in the chart. Make sure these forms are signed by the patient.

    Every test should have an interpretation and a report. There are no specific guidelines on how to interpret a report; the interpretation simply has to exist in the records. However, you cannot bill for a test when new or changed pathology is absent. An example of this would be extended ophthalmoscopies. If the patient has a new retinal tear, it is necessary that you clearly note that on the drawing. If the tear is a known condition and has either resolved or remained stable, you cannot bill for the test, even if it was medically necessary. You can’t bill for tests that show no change.

    Surgical Procedures

    Indications for surgery and procedures must be clearly stated in any clinic notes, which include encounter forms, patient questionnaires and testing results. It’s important that this information is present in the chart and made available for auditors. The patient’s chart must also include a separately identifiable procedure note.

    Recently, CMS Recovery Audit Contractors have audited blepharoplasties. Depending on the payer, blepharoplasties may or may not require documentation of visual fields. Other payers may or may not require photographs. It is important to keep in mind that payer policies can vary by state. Knowing the language of your specific policy will help determine the appropriate documentation.

    For questions related to these topics, email the authors at coding@aao.org.

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    About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.