Proper Documentation for Medical Eye Services Billing

1. Billing Documentation Training For the Medical Eye Services Provider

2. Why document ALL Services Provided? MUST REMEMBER CMS’s (Medicare) Rule… If it isn’t documented, it didn’t happen If it didn’t happen, you cannot bill

3. A Crime! Coding for services not provided is a CRIME Fraud: Billing for services never rendered

4. Documentation Is Coded Proper documentation of services provided results in the ability to assign the proper procedure and diagnosis codes

5. Medical Eye Services Covered • Billable to medical insurance • Office Visits • Diagnostic Testing (report of findings must be in patients chart) • Surgical Procedures (surgical report must be in patients chart) • Office Procedures (minor surgical report must be in chart) • Refraction (seldom covered)

6. E/M Codes (Evaluation and Management) Used to code Office Visits for medical eye services

7. Patient Status Factor New patient Established patient

8. New Patient Has not received any professional service in last 3 years from: The same Provider From another Provider of the exact sameSpecialty and subspecialty and in same group New patients more labor intensive for Provider and staff

9. Established Patient Has received professional services in last 3 years from: The same Provider or Another Provider of exact same specialty and subspecialty in same group Medical record available with current, relevant information

10. E/M Levels Are Divided Based On Key Components (KC) Contributory Factors (CF) Every encounter contains varying amount of KC and CF

11. Key Components History Examination Medical decision making

12. Encounters More of each component/factor Higher level of service Less of each component/factor Lower level of service

13. Four Elements of a History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH)

14. Chief Complaint (CC)—Subjective Reason for encounter Patient’s current complaint Usually presented in patient’s own words Documented in medical record for each encounter Required for all levels of service May not be stated as “CC” but is inferred from documentation

15. History of Present Illness (HPI)—Subjective Chronological description of the development of patients current illness from the first signs and/or symptoms or from the previous encounter to present. Alternatively, you can record status of at least 3 chronic conditions or inactive condition Ie: controlled, worsening, improving

16. History of Present Illness (HPI)—Subjective • Patient describes HPI • If patient cannot answer for themselves, a parent, guardian, or other may provide • Provider must document

17. 8 Elements of HPI • 1.Location-(Which eye or eye segment AND condition-Eye Pain, Dry Eye or Diagnosis-Glaucoma, Cataract) • 2.Quality-(Ache, Irritation) • 3.Severity-(Severity of Condition or Diagnosis) • 4.Duration-(Started 3 days ago)

18. 8 Elements of HPI (Con’t.) • 5.Timing-(Continuous, comes & goes) • 6. Context-(Cause) • 7. Modifying Factors- Does anything make it better or worse (Cold compress helps) • 8. Associated Signs or Symptoms (Blurred Vision)

19. Provider and Patient Dialogue Examples Example 1. Condition easily described by Patient: Bilateral floaters (location) Affect Vision (quality) Started one year ago (Duration) Occurs daily (timing) Example 2. Diagnosis not easily described by patient: Bilateral Glaucoma (location) Increased Optic nerve head (severity) Diagnosed six months (duration) continuous timing) .” NOTE: Both examples show 4 elements of HPI

20. Review of Systems (ROS)—Subjective Record the patients positive and negative findings in each body system as it relates to the chief complaint

21. Extent of ROS Depends on CC Example: Do not usually review musculoskeletal system for CC of eye pain Example: A patient who has sustained trauma from an auto accident and cannot discern difference Medical necessity for the number of OSs inventoried must be implied or documented

22. Systems in ROS Constitutional—General, Fever, Weight Loss or Gain Eyes—Organ System (OS) Ears, Nose, Mouth, Throat (OS) Cardiovascular (OS) (Cont’d…)

23. Systems in ROS (…Cont’d) Respiratory (OS) Gastrointestinal (OS) Genitourinary (OS) Musculoskeletal (OS) Integumentary (OS) (Cont’d…)

24. Systems of ROS (…Cont’d) Neurologic (Neurological) (OS) Psychiatric (OS) Endocrine (OS) Hematologic/Lymphatic (OS) Allergic/Immunologic (OS)

25. Past, Family, and/or Social History (PFSH) Past and Social History contains relevant information about past: Major illnesses/injuries Operations Hospitalizations Allergies Immunizations Dietary status (Cont’d…)

26. Past and Social History (…Cont’d) Social history contains relevant information about: Sexual history Other relevant social factors (Example: Employment) Past-present medications Social tobacco/alcohol use

27. Family History Health status of family members: Parents Siblings Children Family history items related to CC

28. History Levels Four history levels: Problem focused Expanded problem focused Detailed Comprehensive

29. Summary of Elements Required for Each Level of History • Must have 2/3 for established patient • Must have all 3 (HPI, ROS & PFSH) for new patient

30. Examination—Objective (Hands-on) Four levels of examination: Problem Focused Expanded Problem Focused Detailed Comprehensive

31. Elements of Medical Eye Examination • Test visual acuity (does not include determination of refractive error) • Gross Visual field testing by confrontation • Test ocular motility including primary gaze alignment • Inspection of bulbar and palpebral conjunctivae

32. Elements of Medical Eye Examination (Con’t.) • Ocular adnexae including lids, lacrimal glands and drainage, orbits & preauricular lymph nodes • Pupils and irises including shape, direct and consensual reaction, size, and morphology • Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film

33. Elements of Medical Eye Examination (Con’t.) • Slit lamp examination of the anterior chambers including depth, cells and flare • Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex and nucleus • Measurement of the intraocular pressure

34. Elements of Medical Eye Examination (Con’t.) (Through Dilated Pupils) • Optic disc size, C/D ratio, appearance and nerve fiber layer • Posterior segments including retina and vessels

35. Remember Extent of examination depends on needs of patient and expert judgment of provider

36. Medical Decision Making Complexity (MDM) Level of MDM is significantly different for: Patient A uveitis Patient B retinal detachment

37. Three Elements of Medical Decision Making (MDM) Number of diagnoses or management options Minimal, limited, moderate, or extensive (Cont’d…)

38. Elements of MDM (…Cont’d) Amount and/or complexity of data to be reviewed by Provider Minimal, limited, moderate, or extensive (Cont’d…)

39. Elements of MDM (…Cont’d) Risk of complications or death (morbidity or mortality) Minimal, low, moderate, or high

40. Four Levels of MDM Complexity Straightforward Low Moderate High

41. Management Options Based on number of possible diagnoses (definitive or differential) and/or various ways condition can be treated

42. Amount or Complexity of Data • Remember, If you think it, ink it! • If a diagnostic service (test or procedure) is ordered, planned, scheduled or performed at the time of the encounter, the type of service should be documented • The review of lad, radiology and/or other diagnostic test should be documented. A simple notation such as “WBC elevated”

43. Amount or Complexity of Data • A decision to obtain old records or decision to obtain additional history from the family or caretaker should documented • Relevant finding from review of old records or from history from family or care taker should be documented • The results or discussion of labs, radiology or other diagnostic test should be documented • The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.

44. Risks Risks of morbidity (poor outcome), complications, or mortality (death) with problem and/or treatment (Cont’d…)

45. Risks Other diseases or factors that affect risks Diabetes Extreme age (Cont’d…)

46. Patient Risk Levels

47. Summary of Elements Required for Each Level of MDM Only 2 of 3 categories must meet or exceed the element stated to assign the level

48. Summary of Codes & Levels

49. Summary of Documentation Needs • If its not documented, it didn’t happen • Must always have a chief complaint on the progress note • Gather as much detail as possible of CC (8 elements) • Notate, the PFSH from earlier dos was reviewed and initial • More of each component/factor • Higher level of service • Less of each component/factor • Lower level of service • Complete a report of any procedure or diagnostic test

50. Resources • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf