Managing the anterior segment in today’s ophthalmic practice can be complicated; there are so many different aspects to consider when it comes to disease states and proper evaluation. You really have to be on top of the clinical research to be able to identify potential areas of diagnosis and treatment. Patients can present with any number of ocular complications, including ocular allergy, dry eye, meibomian gland dysfunction, ocular infection (with and without systemic involvement), keratoconus, irregular astigmatism and corneal complications secondary to contact lens wear or topical medications, just to name a few.
Recording the Medical Visit
While gathering the pertinent information from the patient’s history and ocular exam is paramount to reaching the correct diagnosis, it’s also critical to properly create the medical record. Your listening skills and the technology you employ will help determine how accurately you capture all of that information in the medical record. Keep in mind that the bar for clinical detail in the record has been raised significantly with the incorporation of the ICD-10 in October 2015.
All clinicians must adhere to the same fundamental principles throughout the patient encounter, starting with the initial meeting, whether it be on the phone, online or in your office. The first step is to capture the true nature of the patient’s reason for the visit. If the patient initiates the call, find out why they are contacting you. Was it because they are returning for follow up or additional testing? If so, that means you have to pull up their medical record to find out what you are actually having them back for. Of course, it is imperative to capture or verify every patient’s insurance information and deductible status on each and every visit.
The severity of the problem a patient presents with or for which you are having them return for follow up determines the level of history you need to perform, which then governs the level of examination you need to perform. Combined, these two points provide you with the clinical information necessary to perform the appropriate level of medical decision-making that leads to a proper diagnosis. With that under your belt, you can establish the diagnosis, implement a treatment plan and follow the patient accordingly.
With all of the technology we have today, it is very important to not lose sight of the fact that medical necessity has to be established for every special ophthalmic test you order and perform. Technology cannot replace your clinical examination, but should be used to complement or augment your testing protocol. For example, you cannot take a picture of the anterior segment just because you want to—you must have a specific reason for taking the picture and demonstrate the necessity in the record. Also remember, just because a test is deemed a bilateral test doesn’t mean that you perform it bilaterally when you have a unilateral condition. In cases such as this, the ICD-10 laterality and the CPT laterality must match, most likely through the use of appropriate modifiers.
Coding protocols also are important to follow when initiating a treatment plan. For example, if you were treating moderate to advanced dry eye, you cannot automatically jump to using an amniotic membrane for treatment. You must first establish that less invasive methods of treatment—such as a pharmaceutical regimen or punctal occlusion—have been tried and failed. This is what establishes the medical necessity of the amniotic membrane. And, most importantly, you must understand carrier policy when treating a patient. In this dry eye case, for example, you must make sure the amniotic membrane you chose is approved for use on the ocular surface and delivers the best outcome, as not all amniotic membrane technology is equal in delivering clinical outcomes.
It is critical that you hone your corneal disease compliance skills in accordance with your clinical acumen; your patients deserve the best outcomes provided by an appropriate diagnosis and treatment—in the end, your practice will be compliant, safe and profitable.Send questions and comments to ROcodingconnection@gmail.com.