As the practice of optometry continues to grow, attention to proper coding of our patient encounters is also growing. Ive been involved in medical coding in eye care for nearly 23 years, and nothing makes me happier than when I meet a colleague who tells me that incorporating these principles into his or her practice has made a significant difference to his or her professional satisfaction, patient care and income.
But, as the conversation continues, it also greatly disturbs me when I hear about coding for maximum income, rather than by proper coding principles. When I ask why, the reply is often, I went to a lecture where the speaker said that if I did it this way, it would be like printing money. This is simply not proper, not correct, often not trueand not anything like the intended purpose of the clinical coding guidelines.
The other popular phrase, Coding is an art, not a science, also disturbs me. While this may have had some truth a long time ago, its simply not the case in 2008. Coding today is much more a science than an art. Why? Because in todays world, there are regulations that govern how you interpret and communicate your medical services to the medical carrier.
In the clinic, evidence-based medicine is the current standard by which we practice. On the coding side, the rule of medical necessity governs each and every procedure and test that we do.
Whats a Medical Necessity?
The U.S. Department of Health and Human Services defines medical necessity as, Services or supplies that are proper and needed for diagnosis or treatment of the patients medical condition; furnished for the diagnosis, direct care, and treatment of the patients medical condition; meet standards of good medical practice; and are not mainly for the convenience of the patient, provider or supplier.1
Consider these four criteria for medical necessity:
1. The physician must establish that the test or procedure is necessary and will add to the diagnostic or treatment plan for the patient, and sign an order in the medical record for the test.
2. The physician must follow the prevailing rules established by either the National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) for the particular procedure or test.
3. The physician must demonstrate the need for the test or procedure through establishing an ICD-9 diagnosis at the highest level of specificity.
4. The physician must have met the indications of coverage, medical necessity rules and utilization guidelines for the specific test or procedure, and must have clearly docu- mented the medical record to satisfy those items.
Often, when we consider new technology, we base our decision to provide better care for a patient on a break-even analysis thats too simple: How many procedures must I do each month to make my payment? As we incorporate better technology, we must look at issues far greater than the dollars and cents involved.
Performing a procedure on a patient just because you may have a covered diagnosis isnt enough to justify doing the test. Performing a procedure just because you heard about it in a lecture isnt enough. Performing a procedure just because the sales rep said it was OK isnt enough. We as physicians must meet a higher standardthat of proper and appropriate medical necessity to benefit the outcome of our patient.
Coding today is not an art of manipulating the system just to get paid, but a science of navigating the regulations and guidelines that allow us to practice to the fullest scope of our training. We need to understand and utilize all resources necessary to fulfill the mandate for appropriate medical coding and practice it daily. After all, our patients are counting on us.
1. Centers for Medicare & Medicaid Services Web site. Medicare Learning Network. Reference information. Available at: www.cms.hhs.gov/MLNProducts/downloads/18reference.pdf (Accessed April 27, 2008).
Clinical Coding Committee
~John Rumpakis, O.D., M.B.A., Clinical Coding Editor
~D.C. Dean, O.D.
~David Mills, O.D., M.B.A.
~Laurie Sorrenson, O.D.
~Rebecca Wartman, O.D.