This month’s issue covers a number of dry eye and corneal topics, so I thought it would be valuable to relate those with our discussion here since the process of medical record documentation and coding are so intertwined. Whether we are talking about the diagnosis and treatment of meibomian gland dysfunction, corneal neuropathy or contact lens intolerance due to dry eye, or how to conduct a proper dry eye assessment, it is critical that the physician and their care team develop a process that does two things simultaneously: creates an accurate medical record from which you can properly code and prevents audit triggers with the carrier during the claim submission or post-payment review process.

When a Patient Comes in

Let’s start with a proper assessment of the patient. Keep in mind that this actually starts with the patient contacting the office, whether by phone or through your online portal. The most important question to ask the patient is why they need to see the doctor. We need to obtain the chief complaint as early as possible in the care sequence so that we can allocate the necessary and appropriate resources to that encounter (e.g., time, staff, facilities) as well as allow the office to properly inform the patient about the status of any third-party benefits. 

Once you establish the reason for the visit, the new E/M definitions and coding rules now allow you to perform a medically appropriate history and physical examination. Determine just how much information and what type of information that you require. 

For example, you may find it important to provide every patient with a qualified questionnaire that allows you to assess whether they have a clinically relevant sign or symptom of dry eye. If they fill it out, this allows you to have standing orders for your staff to perform CLIA-waived tests like osmolarity (83861) and InflammaDry (Quidel; 83516) before you see the patient—just like your physician often does by having labs done before the encounter.

Test the Same Day

Once you have conducted your history and examination, you must diagnose the patient, order additional tests (if necessary) and recommend a treatment program. The key, again, is the sequence. Other than CLIA-waived tests with standing orders based upon the patient’s responses to a qualified questionnaire, all special ophthalmic testing must be done after you have seen the patient, established appropriate medical necessity for the test(s) and properly ordered them. This prevents an audit trigger in your medical record by ensuring that you have examined the patient, established the necessity for the test and ordered the test—in that order.

Many are under the misconception that you have to bring the patient back to do additional special ophthalmic testing; that is simply incorrect. All special ophthalmic testing may be done on the same date and the same session as any examination services provided, irrespective of who is paying for them.

If you are providing treatment on the same day as the examination, particularly surgical treatment, such as the placement of an amniotic membrane, please be aware of the CCI rules and regulations specific to the particular code pair being performed and appropriate use of modifiers, if necessary. 

Another audit trigger is the inappropriate or excessive use of modifiers, particularly modifiers -25 and -59. Ensure that your use of the modifier is not only correct but that you also fully understand and comply with the definition of the modifier. Keep in mind coding rules surrounding performing minor surgical procedures (those with a global period of less than 90 days) and office visits on the same date of service.

Other procedures performed may not yet have rules or reimbursements established, such as BlephEx (92499) and TearCare (Sight Sciences; 0653T), because they would use the unlisted ophthalmic procedure code or have a Category III code. 

In diagnosing and treating conditions associated with dry eye, MGD or more advanced conditions such as corneal neuropathy, it is comforting to know that you only have one set of rules to follow—but the sequencing of those rules is critical to your coding, reimbursement and audit prevention success.

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Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.