The other side of the coin in glaucoma management is following the rules of creating, maintaining and managing the medical record; when properly done, it can prevent claim rejections and unnecessary exposure to carrier audit. The good news is that these rules are simple, straightforward and easy to follow.

State Your Clinical Rationale

When ordering any special ophthalmic test, you will submit to a third party for payment, clearly establish why you ordered the test and why it’s necessary for the patient. Each test must meet the requirement for medical necessity, which is based on a clinical finding discovered during the patient exam. Your medical record must contain a written statement of this medical necessity. If you keep in mind stating what you need to do, why you need to do it and when you need to do it, you will be in compliance with most medical necessity provisions of carrier rules.

Be Specific

When I do an internal audit for a practice, I frequently see in patient records what many doctors call a “glaucoma check.” The chief complaint (CC) might say, “Patient returning for glaucoma check,” or sometimes nothing more than, “IOP check.” Simple phrases mean different things to different people. Avoid all-purpose phrases in the medical record. Rather, describe exactly why the patient is returning to the office.

The CC requirement can be fulfilled properly if you direct the patient to return to the office for a specific reason at an appropriate interval. The plan section of your medical record should include a statement such as: “Patient to return to clinic for evaluation of IOP and optic nerve Q3 months or PRN should additional symptoms arise,” rather than, “RTC three months for glaucoma check.” The former statement tells the record what you want the patient to do and why. 

When the patient returns, the CC should read: “Patient returning to clinic per doctor-directed order for evaluation of IOP and optic nerve.” If you have orders pending for special ophthalmic testing, list them in both the plan and the reason for the visit.

The same patient may require different levels of examination and testing on different visits, and our records need to properly reflect that.

Complete Requirements

Each special ophthalmic test you perform requires its own interpretation and report (I/R) to be considered complete or billable, and each test and I/R must stand on its own. An I/R should contain:

a. Clinical findings.
b. Reliability of the test.
c. Comparative data.
d. Clinical management—how the test results will affect management of the condition/disease, e.g.:

i. Change, increase or stop medication.
ii. Recommendation for surgery.
iii. Recommendation for further diagnostic testing.
iv. Referral to a specialist or sub-specialist for additional treatment.

If you haven’t completed an I/R for each clinical test performed, then it is deemed that the test was never performed and was in conflict with your provider agreement or contract.

Keep an Eye on Updates

The combination of what CPT codes are allowed to be performed on the same date of service and the modifiers needed if you have to break an established rule are updated quarterly, so it is vital to use some form of technology, such as CodeSafePlus, to keep up to date with the rules. Carriers follow these rules when approving or denying claim submissions.

The various component output of code combination rules shows that:

  1. The rule is Active or Inactive.
  2. The code combination is Allowed or if there is a code Conflict.
  3. The Conflict can be overridden by use of a modifier or not.
  4. The Administrative Explanation or reason for the Conflict rationale.

Understanding these is essential to getting paid properly on your submitted claim and avoiding audit exposure. Improper use of modifiers is a primary trigger for carrier audits.

Providing great clinical care for your glaucoma patient is only half the battle; maintaining a proper clinical record that establishes medical necessity, clearly states your orders and follows the rules of the CPT and CCI is just as important for clinical 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.