Often, when focusing on medical record compliance and coding of a particular procedure, it is easy to get lost amid the rules, regulations and guidelines and forget about clinical care—more specifically, the patient. This may be particularly true for patients with more than one complication. Of course, these are precisely the patients who need your undivided attention the most.
Concurrent anterior segment conditions, for example, are quite common, particularly with dry eye and ocular allergy. One survey found 40% of the participants reported symptoms of ocular allergy at least once during the previous year, and researchers have noted dry eye may be present in as much as 30% of the US population.1,2 Combine that with contact lens wear and you have the potential for clinical confusion, a sloppy medical record, over or under coding and lost revenue.
So let’s set the record straight on how these concomitant conditions should be handled in the medical record, particularly in the era of health care reform where efficiency and effectiveness are paramount.
Dry eye, allergy and contact lens wear are often looked at as annuity disease states—they require constant, continual management. When you have a patient diagnosed with dry eye, allergy or both, or they are contact lens wearers, it’s important to record all of these conditions as reasons for the visit or chief complaint each time you see them for a scheduled follow-up. Your record should read something like: “contact lens patient returning per doctor-directed order for further diagnostic evaluation and follow-up for dry eye (or ocular surface disease) and allergic conjunctivitis. Additional symptoms noted since last visit are…”.
The greatest specificity you can provide in the medical record leads to clinically appropriate case history, level of physical exam, medical decision-making and, ultimately, a more accurate code for the encounter.
It’s not unusual to deal with a patient whose allergic response is elevated due to a compromised ocular surface, and whose contact lens wearing time is reduced or quality of vision is affected—all on the same visit. Does that mean you can code higher-level visits? The answer is yes and no.
Coding Just Got Complicated
Multiple diagnoses do play a role in elevating the level of an office visit by affecting the case history, the medical decision-making and, to a lesser degree, the physical exam, but only if you are recording items properly in the record (don’t forget the concept of medical necessity).
Do not do anything to unnecessarily embellish the medical record simply to elevate the visit to another level. The same concept applies to additional point-of-care testing, such as MMP-9, osmolarity, anterior segment photography (including meibography) and topography, to name a few. For example, many practitioners follow a clinical protocol for certain disease states. However, it’s often unnecessary to do every test within the protocol on every patient. A protocol should be viewed as a toolbox from which a physician chooses the test or tests that provide the information necessary to manage the case, not just acting in a confirmatory fashion.
Additionally, you should never embellish the medical record to justify the frequency of office visits throughout the year to manage these conditions.
The implementation of ICD-10 has provided all stakeholders with a very discrete metric by which practitioners are measured. While these three conditions are not specific measurement outcomes with respect to merit-based incentive payment systems, a practitioner can easily be measured by the number of office visits performed in a given period of time, providing an easy path to calculate the economics of disease states and the clinical efficiencies and effectiveness of a practitioner. Make sure you rely only on what you can support by the medical necessity noted in the record when you are calculating the economic upsides of these concomitant conditions.
Knowing how handle the medical record at the outset can keep your mind focused on what’s important: the patient, who needs your expertise to help them maintain comfortable, productive lifestyles. n
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1. Singh K, Axelrod S, Bielory L. The epidemiology of ocular and nasal allergy in the United States 1988-1994. J Allergy Clin Immunol. 2010;126(4):778-83.