Medical Records Coding:Choosing 92000 Codes

Accurately

Charles B. Brownlow, OD, FAAO cbrownlow@revolutionehr.com

January 10, 2013

• Part I: November 29, “The Reality of Audits”• Part II: December 17, “Building Your Medical

Records Compliance Program”

•Part III: January 10, “Medical Records Coding…the 92000 Office Visit Codes”

Plan of Action for this Webinar

Series

Multiple Roles of Today’s Medical Records

• Excellent patient care• Excellent internal communication

(patient/docs/staff)• Excellent external communication (other

providers/caregivers)• Accurate choices of procedure and

diagnosis codes• Compliance with national rules (CPT/ICD-9)• Compliance with rules of Medicare and

other insurers

National Resources• Current Procedural Terminology, CPT© American

Medical Association– Only nationally accepted source for definitions

and codes for choosing and reporting visits and procedures

• International Classification of Diseases, 9th Edition– Only nationally accepted source for diagnosis

codes• Healthcare Common Procedure Coding System

(HCPCS)– Level I = CPT codes– Level II = products, supplies, services not in

CPT

More Resources…• Centers for Medicare and Medicaid Services,

www.cms.gov– Medicare Learning Network resources

•Evaluation and Management Services Guide, December 2010 (99000 office visit codes)

•Medicare Fraud & Abuse: Prevention, Detection and Reporting

• American Optometric Association– aoa.org/coding– askthecodingexperts@excelod.com– Monthly webinars, usually 2nd/4th Tuesdays,

11:00 a.m

The Logic of Documentation

• Knowing the rules ensures that you do things correctly, on purpose

• Knowing the rules and applying them will help you create better records

• Knowing the rules will make you far more confident when you are audited by Medicare or other payers

The ‘Logic’ of Documentation

• Every record must include– The site of service– The medical necessity of services provided– Accurate, thorough, legible record of all that

happened during the encounter•Case History•Physical Examination•Medical Decision Making•Subjective/Objective/Assessment & Plan

(SOAP)•Date and legible identity of the observer

Logic…

• Rationale for services should be documented or easily inferred

• Patient’s past and present conditions need to be available to the physician

• Health risks should be identified• Patient’s progress, revisions in treatment,

diagnosis changes should be documented• All codes used for reporting the care must be

supported by documentation and chosen based on national rules

“Reasonable and Necessary”

• Nothing should be billed unless it was reasonable and necessary– Furnished because it was related to the

identifying of, direct care of, and treatment of the patient’s medical condition (not for the convenience of the patient, physician)

– Compliant with the standards of good medical practice

Reporting Eye Care Visits

• Visits may be reported with either of two sets of codes– General ophthalmological services

• Intermediate, 92002 (new)/92012(established)• Comprehensive, 92004 (new)/92014 (established)

– Evaluation and Management Services• New patient services, 99201-99205• Established patient services, 99211-99215

Note: New patient is one who has not been seen by you or another doctor of exact same specialty here or in another practice of same ownership in previous three years, date to date

Choosing a 92000 Code

• As with all services, we must use these codes only when the documentation matches the definitions in CPT

• Most visits can be reported using either 99000 or 92000 codes (70-80%)– Approximately 20% of the eye doctors’

charts we review are missing at least one requirement for the intermediate or comprehensive ophthalmological services and can only be coded as a 99000 visit

92000 Codes: General Ophthalmological Services

• General Ophthalmological Service codes, as all other CPT codes, are designed to report medical eye care visits

• General ophthalmological service codes may be used to report non medical eye care

• Refraction is a separate service (92015) and is not included in any other code, unless required by contract with payer

CPT Definition for Intermediate

Ophthalmological ServicesNote: Current Procedural Terminology(CPT ©

American Medical Association) is the only accepted source of definitions for these services.

“Intermediate ophthalmological services describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy…with initiation (or continuation) of diagnostic and treatment program.”

New (92002) or established patient (92012)

CPT Requirements for 92002/92012

Payers may develop their own interpretations of these definitions, but the elements that are clearly included in the CPT definition are:

1. A new or existing condition…2. complicated with a new diagnostic or management

problem not necessarily relating to the primary diagnosis

3. History4. General medical observation

CPT Requirements for 92002/92012

5. External ocular/adnexal examination

6. Other diagnostic procedures as indicated

7. Initiation (or continuation) of a diagnostic and treatment program

If one (or more) of these elements is missing, the visit cannot be coded as intermediate ophthalmological service.

CPT Definition for 92004/92014

• “Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.”

• New (92004) or established (92014) patient

CPT Requirements for 92004/92014

Again, payers may develop their own interpretations of these definitions, but the elements that are required by the CPT definition are:

General evaluation of the complete visual system

1. History

2. General medical observation

3. External examination

4. Ophthalmoscopic examination (with or without cycloplegia or mydriasis)

CPT Requirements for 92004/92014

5. Gross visual fields6. Basic sensorimotor examination

7. Initiation of diagnostic and treatment program

If one (or more) of these elements is missing, the visit cannot be coded as comprehensive ophthalmological service.

Initiation of Dx/Tx Program Is Critical Component of Medical

Record• Most likely target of reviewers/auditors of eye

care records• Visit will be downcoded or rejected if coded

as ophthalmological service and without initiation of diagnostic/treatment program

• No detailed nationally accepted, detailed definition, so…– Every office must have their own definition of

what’s included in initiation (continuation) of diagnostic and treatment program

Your Office’sDefinition of Initiation of

Initiation of Dx/Tx Program Is…• Probably will include 15-20 items, ie:

– Diagnoses pertinent to today’s visit– RTO

• For recheck• For additional tests• For treatment

– Rx meds– Rx specs

More Dx/Tx

– Rx CLs– Refer for Dx/Tx– Recommended OTC meds– Lid hygiene, lid scrubs, etc.– Ergonomic adjustments at work or home– Adjustments in school environment– Refer to another doctor or clinic for Dx/Tx– Etc.

Auditors are ‘Focused’ on the 92000 Codes

• Why?– Many ODs and OMDs use them almost

exclusively

• Why is that a problem?– 15-20% of the charts we review are missing at

least one required element of the 92000 codes– Most ODs and OMDS have never read the CPT

definitions for the codes– Auditors love to challenge doctors’ ‘initiation of

diagnostic and treatment program’

And in Conclusion…• There are lots of things to learn with

respect to medical record keeping, coding, claims submission, Medicare and other payer rules.

• There is no alternative to learning, carefully doing, and properly reporting

• It takes effort, but it’s not that tough and it is well worth the effort, in better patient care, better communication, enhanced revenues for the practice, better relationships with the payers, and in improved peace of mind!

Next Month’s Webinar…Choosing a 99000 Code

• CPT definitions are more subjective• Documentation Guidelines for the

Evaluation and Management Services add more details to the definitions

• As with all codes, 99000 visit codes must be billed only when the content of the record matches the CPT definition for the code

• Most providers have ignored this stuff too long– Commit all doctors and staff in your practice to

focusing on patient care and compliance with national rules and payers rules

– Conduct internal audits of each doctor’s charts each 3-6 months (e.g. 5-10 charts/audit)

– Develop in-office protocols to ensure consistent record keeping and compliance with payers’ rules

Procrastination is passé

Questions?

cbrownlow@revolutionehr.com

Additional webinars in this series will be based on your feedback and on current medical records

challenges facing eye care providers