As we usher in a new year, the timing is perfect to look back to ensure that good processes are in place and use our future time wisely to prepare for upcoming coding changes.

A Good Foundation

Your medical record is the cornerstone of your practice and the only legal record of patient care delivered. Medical record compliance is paramount for everyone in your practice. Make sure you maintain a thorough, well-documented and accurate medical record, as it is the key to providing the best care to the patient and to defending what you have been paid, should you be called upon to do so. The foundational elements should always contain:

  1. Reason for visit (ideally captured when the patient made the appointment)
  2. Chief complaint
  3. Delineation of any standing orders (routine testing or non-medically necessary services)
  4. Medical necessity clearly established for: type of visit (920XX vs. 992XX vs. S062X), level of visit, any additional testing or procedures performed
  5. Clear record keeping and patient signature if an advanced beneficiary notice (ABN) is used
  6. Clearly written assessment and plan—always include what you want the patient to do, why and when it should be done.

The Coding Triad

To thrive in a third-party paid world, you must understand the “coding triad”: coding, coverage and reimbursement. Each of these has a specific function and meaning.

Coding. This is the only legal way to describe what happened during the physician/tech/office/patient encounter. Each code has a specific definition and set of characteristics you must know before you use it. Coding properly isn’t only for insurance companies. You must code properly for every patient, irrespective of who is paying.

Coverage. When a patient has a form of payment assistance (insurance, medical savings plans, etc.), the third party generally has policies dictating if payment assistance will be provided and the conditions necessary for them to provide it. Coverage policies usually provide a clear explanation of the indications and limitations with respect to coverage and medical necessity for the coverage to exist and be allowed.

Reimbursement. This is calculated by different methods depending on the third-party payer. Managed vision care plans generally provide a predetermined contract rate based on internal supply/demand/use/profit calculations. Medical carriers usually follow the Resource Based Relative Value System where each CPT code has a total relative value unit and is further modified by your geographic location and dollar-based conversion factor. There are a couple of considerations with reimbursement: 

a. Before you join the plan, know how they calculate reimbursements.

b. Keep current on the maximum allowables for each service, procedure and materials you provide. The total payment is often the sum of the patient copay and carrier payment.

c. For maximum profitability, analyze your fees quarterly to ensure you are charging properly considering your carrier’s maximum allowable values.

d. If you don’t like your carrier’s reimbursement rates, you don’t have to be a member of the plan. If renegotiating your reimbursements isn’t successful, you always have the option to not participate.

e. One crucial pointer: you must charge everyone equally for the services you provide. You must have one fee per CPT code, no matter who is paying. For example, if you charge $175 for a 92004, you must charge $175 to every patient who gets a 92004, whether they have payment assistance or are paying out-of-pocket. 

A firm grasp of these coding triad and medical record compliance concepts is critical for everyone in your office providing patient care. The medical record is really a reflection on your clinical thought process in managing the patients care within your local standard of care. Practice and perfect these skills and you, your practice and your patients will all win. 

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