Documenting Eye Exams Financial Interest S.O.A.P. Covered Services Chief Complaints Chief Complaints

Documenting Eye Exams Financial Interest

ASCRS-ASOA Symposium & Congress Practice Management Program San Diego, California I acknowledge a financial interest April 17-21, 2015 in the subject matter of this

Presented by: Patricia J. Kennedy, COMT, CPC, COE presentation.

S.O.A.P. Covered Services

• The standard documentation of an • Subjective entry dictates whether the examination uses the S.O.A.P. method: service is covered or not – Coverage of eye examination is based on the – S – Subjective pppurpose of the exam, not on the findin gs – O – Objective – Without complaint, exam is not covered even though doctor discovers a pathological – A – Assessment condition – P – Plan – Must always ask: Why is the patient here today?

3 4

Chief Complaints Chief Complaints

• The history can be obtained from the patient, • Elaborate on the patient’s primary caregiver, referring physician. For a new complaint: patient ask about: – Which eye, OS/OD/OU? – Vision Problems – blurring, clouding, diplopia, distortion, – When was the onse t? floaters, photopsia, etc. – Comfort Problems – itching, burning, aching, scratching, – Is this problem constant or episodic? photophobia, etc. – What makes it better or worse? – Appearance Problems – redness, swelling, discharge, – How severe is the problem? scaling, etc. – Does the problem prevent you from activities – Another doctor noted – AMD, glaucoma, cataract, etc. of daily living?

5 6

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 1 Chief Complaints Chief Complaints

• Established Patient - complaint, symptom – Should record patient’s complaint or indicate or previously diagnosed condition “no new complaint” or “no changes” – Typically found in the Plan entry of the – If this is an “off-cycle” visit, must treat patient previous visit if this is scheduled return visit as if it were a new encounter • For example: • Must be an acute complaint to satisfy the medical – 4 month POAG IOP check and HVF 24-2 necessity for the service – 6 month diabetes evaluation – 1 year cataract check – 2 month AMD check and Macular OCT

7 8

Chief Complaints

• The chief complaint also provides the basis for Office Visits the nature of the History of Present Illness (HPI) – This is one of the most significant issues in documenting E&M services – The HPI must be obtained by the physician • Without a chief complaint, exam is considered Evaluation and Management Codes routine and not billable vs. • Cataracts, YAGs & Blepharoplasties also require Ophthalmic Codes lifestyle impairments

Office Visits Components of E&M

• New Patient • Established Patient • E&M services consist of 7 components – 99201 – 99211 – History Taking (3) – 99202 – 99212 • History of Present Illness (HPI) • Review of Systems (ROS) – 99203 – 99213 E&M E&M • Past, Family, and Social History (PFSH) – 99204 – 99214 –Examination (1) – 99205 – 99215 – Medical Decision Making (3) – 92002 – 92012 • Diagnoses and Management Options – 92004 Eye – 92014 Eye • Data to be Reviewed • Risk of Complications

11 12

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 2 History Taking Examination History of Past, Family and/or Present Illness Review of Systems Social History Type Ophthalmological Presenting Problem Level of Exam brief (HPI) (ROS) (PFSH) of History Elements Brief N/A N/A Problem Focused (99201, Minimal (1-3 Elements) 99212) None Required Minimal 99211 (Med check) Brief Problem pertinent N/A Expanded Problem Self Limiting or (1-3 Elements) (1 System) Focused (99203, 99214) 1-5 elements Problem Focused (()99201, 99212) Minor Extended Extended Pertinent (1 of the 3 - Detailed (99214,) Low to Moderate Expanded Problem Focused (99202, (4+ Elements) (HPI + 2-9 systems) P, F, or S) 6-8 elements Severity 99213) Extended Complete Complete (NEW: 1 Comprehensive (99204, (4+ Elements) (10 or more each of the 3; EST: 99205, 99215) Moderate Severity 9-12 elements Detailed (99203, 99214) systems) 1 each from any 2 of the 3) Moderate to High 13 elements Comprehensive (99204, 99205, 99215) All three components of History Taking must be met or exceeded for each level. If one Severity Including mental status component is not met, drop to the next lower level.

13 14

TABLE OF RISK (Unofficial)

Medical Decision Making Level of Presenting Problem(s) Diagnostic Tests Management Options Risk Ordered Selected Number of Minimal • One self-limited or minor problem (e.g., itchy • A-scan or B-scan, Visual •Rest, lid scrubs, superficial diagnosis and/or Data to be Risk of eyelids, non-irritated bump on lid). Fields. dressings. Type of Decision Making Management Reviewed Complications Low •Two or more self-limited or minor problems; •Fluorescein angiograms, skin •Over-the-counter drugs •One stable chronic illness (e.g., glaucoma biopsies. •Minor surgery with no identified Options suspect, cataract); risk factors, (e.g., insertion of •Acute uncomplicated illness, or injury (e.g., punctum plugs, epilation, Minimal Straight Forward (99201, 99202, allergic conjunctivitis, controlled glaucoma). removal external foreign body) Minimal Minimal (Suggest 1-2) 99212) Moderate •One or more chronic illnesses with mild •Paracentesis of vitreous for •Minor surgery with identified exacerbation, progression, or side effects of diagnostic study. risk factors Limited treatment; •Elective major surgery with no Limited Low Low Complexity (99203, 99213) •Two o or more stablestable chronicchronic ill illnesses;nesses; ididentifiedentified riskrisk factorsfactors ( (ee.g ., (Suggest 3-4) •Undiagnosed new problem with uncertain blepharoplasty, etc.) Multiple prognosis; •Prescription drug management Moderate Moderate Moderate Complexity (99204, 99214) •Acute illness with systemic symptoms; (e.g., glaucoma) (Suggest 5-6) •Acute complicated injury; for example, trauma •Closed treatment of fracture victim in ER with multiple, undetermined (e.g., orbital blow-out). Extensive problems. Extensive High High Complexity (99205, 99215) High •One or more chronic illnesses with severe •None for ophthalmology in •Elective major surgery with (Suggest 7+) exacerbation, progression or side effects of the CMS supplement. identified risk factors (e.g., treatment; cataract, glaucoma, retina, etc.) Note •Acute or chronic illnesses or injuries that pose a •Emergency major surgery (e.g., threat to life or bodily function; orbital blow out, repair 2 of the 3 components of Medical Decision Making must be met or exceeded for each level. •An abrupt change in neurological status; for ruptured globe, etc.) example, sudden blindness. •Drug therapy requiring Drop the lowest component and bill the lowest of the remaining components. intensive monitoring for toxicity.

15 16

Determining E&M Determining New Patient E&M

Medical Decision Medical Decision Type of History Level of Exam Type of History Level of Exam Making Making

Problem Focused Problem Focused Straightforward Problem Focused Problem Focused Straightforward

Expanded Problem Expanded Problem Expanded Problem Focused Low Complexity Expanded Problem Focused Low Complexity Focused Focused

Detailed Detailed Moderate Complexity Detailed Detailed Moderate Complexity Comprehensive Comprehensive High Complexity Comprehensive Comprehensive High Complexity New Patient The lowest of the three components determines the overall code. New Patient The lowest of the three components determines the overall code Established patient 2 of the 3 components must meet or exceed the level to determine the code. Low Complexity determines the code 99203.

17 18

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 3 Determining Established Patient E&M Intermediate Eye Exam Medical Decision Type of History Level of Exam Making • CPT Codes 92002 & 92012 Problem Focused Problem Focused Straightforward – Requirements from CPT are usually found Expanded Problem Expanded Problem Focused Low Complexity verbatim in Medicare Local Coverage Focused Determinations (LCDs) Detailed Detailed Moderate Complexity • History Comprehensive Comprehensive High Complexity • General Medical Observation • External & Adnexal Exam Established patient 2 of the 3 components must meet or exceed the level to determine the code. • Other Procedures as Necessary

Type of History and Level of Exam determine the code 99215.

19 20

Comprehensive Eye Exam Comprehensive Eye Exam • CPT Codes 92004 & 92014 • “It often includes, as indicated: – Requirements from CPT are usually found biomicroscopy, examination with verbatim in Medicare Local Coverage Determinations (LCDs) cycloplegia or mydriasis and tonometry. It • History always includes an initiation of diagnostic • Evaluation of the complete visual system and treatment programs.” • General Medical Observation • External & Adnexal Exam • Gross Visual Fields • Basic Sensorimotor exam

21 22

Eye Codes vs. E&M Codes E&M vs. Eye Codes INTERMEDIATE EXAM E&M Eye Code E&M Eye Code New New Established Established  Eye Codes  E&M Codes 99201 $43.98 99211 $20.02  Expanded Problem  Brief Ocular History, Focused History, CC 99202 $75.09 99212 $43.98 CC  Brief HPI, Pertinent 92002 $81.53 99213 $72.94  3-7 Exam Elements ROS  Including Adnexa  6-8 Exam Elements 99203 $109.06 92012 $85.82  GMO  Dilation Not Required 92004 $149.11 99214 $108.34  Dilation Not Required  Medical Decision  No Initiation of Tx  Limited DX/MO (3-4) 99204 $165.91 92014 $124.08 Program Required  Limited amount of data 99205 $208.46 99215 $146.24  Only need 1 Dx to be reviewed  Low Risk - requires minimal treatment plan 2015 CMS Physician Fee Schedule – National Reimbursement

23 24

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 4 OIG Target

Cloned Documentation • Inappropriate payments for E&M Services – OIG will continue to determine to what extent certain E&M services were inappropriate • Will also review multiple E&M services associated with same providers for documentation errors – CMS has noticed increase in identical documentation across services

Electronic Health Records (EHR) Electronic Health Records (EHR)

• Both a blessing… • …and a curse – More efficient – Too efficient - Fills in everything – Legible – Even the nonsense is readable – EilEasily accesse d remo tltely – Accesseddtl remotely - bbh?y whom? – Easily transportable – Easily transportable - to whom? – Searchable – Searchable - by whom? – Comparable – Garbage in garbage out

27 28

Electronic Health Records (EHR) Electronic Health Records (EHR)

• Cloned Documentation – Cloned documentation is seen in both paper – Previous visit findings brought forward and electronic charts including typos & misspelling • Has become a major issue for EHR • Exam, assessment & plan – According to OIG, cloned documentation does – Pre-populating Fields not meet medical necessity requirements for • Load exam with normal findings coverage – Causes documentation to look dubious • Creates contradictions • Was the element actually performed • Makes it difficult to code

29 30

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 5 Patient History History Example #1 • Chief Complaint (CC) & History of Present • Exudative AMD Illness (HPI) – “Pt. states his vision is good, no flashes of bright – Prompts to document 4 or more lights, no blurred vision on OU, no pain, no – Dropdown lists floaters” – Adding nonsensical HPI – The EHR counted 4 elements for the HPI • Patient CC & HPI most important part of • Location: OU the documentation • Quality: blurred, good – Determines if the service is covered • Associated Symptoms: floaters, flashes, pain – Creates the foundation for exam extent • Context: bright lights

31 32

History Example #2 Exam Elements • Exudative AMD • All 14 exam elements are filled in on every – “Pt. states no changes in vision OU since last visit visit. No pain OU. No new floaters or flashes of light OU.” – Does the reason for the visit justify all the exam? – The EHR counted 5 elements for the HPI • Location: OU – Frequency of codes • Quality: new • Medicare would likely deem this not • Associated Symptoms: floaters, flashes, pain medically necessary unless there is a • Timing: last visit significant change in patient’s complaint or • Modifying Factors: light condition

33 34

Assessment Plan

• Failure to update the Assessment • The exact same plan from visit to visit – Diagnoses remain “new” despite previously – Regardless of the reason for the visit being diagnosed • “Canned” Plans that are all inclusive – Diagnoses are all listed despite the reason for – For example the visit in the same order • Cataract is visually significant & interfering with – Diagnoses are listed that are no longer valid patient’s visual funtion [sic]. plan lens caclulations [sic] & cataract surgery. May need to employ Malyugin ring, Trypan blue, or iris hooks.

35 36

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 6 Scanned Documents Scanned Documents

• Patient Registration Paperwork Incomplete • Inconsistently filed – Assignment of Medicare Benefits – From patient to patient • Signature on file – Within a single patient record – Privacy Notice • Smeared or cut-off copies • Missing signatures • Patient identity • Large stacks in one scan • Dates of signatures • Missing documents – Co-management correspondence – Operative notes

37 38

Templates In Summary

• Templates with information to be filled but • History is KEY left blank – Determines IF the exam is covered – Pupil size not documented – Lays the foundation for the extent of the exam • But are PERRLA • Exams should be both E&M & Eye Codes – Cup to disc ratio not documented – Each has requirements • All other disc findings pre-printed including the instrument used for examination – Code is determined at the end of the service • Eliminate cloned documentation – Perform what is necessary today – Document what is found today

39 40

Questions

Rose & Associates 1-800-720-9667 [email protected] www.roseandassociates.com

Rose & Associates 1‐800‐720‐9667 www.roseandassociates.com [email protected] 7