Joe W. DeLoach, OD, FAAOOptometric Business Solutions

Documentation

Isn’t It Just SOAP?

Let’s get it right out there – I am CEO of Optometric Business Solutions . Although I have no financial interest in the company, parts of this lecture strongly promote the services offered by Optometric Business Solutions. I think it is an exceptionally wise use of your money.

DISCLAIMER

No…it is not and never was

So….Isn’t It Just SOAP?

Likelihood of getting audited

100% related to coding practices

Likelihood of LOSING an audit

30% related to coding practices

70% related to medical records documentation (Per CMS!)

But let’s put something right out there…

Here Is What We Have Done Wrong

We have spent too much CE on how to make money, how to “go medical”, how to make sure your diagnosis is

on the “allowed list” and not enough time talking about medical necessity,

reason for the visit, coding ethics and how to really document a patient encounter! (really? OUCH!)

So let’s look at some “myths” of

documentation that made those numbers

happen

Let’s Start With What CPT Says Doctors Are Required To Document

In A Medical Record

Reason for the visit is the most important concept in coding and documentation

But, reason for the visit is the most misunderstood concept in optometry

The reason for the visit ALONE determines the level of examination you conduct and the examination elements needed to address the reason for the visit

Numero Uno – Reason For the Visit

YOU do not get to decide what level of examination you want to perform. It is dictated by the reason for the visit.

Many medical patient encounters by optometrists do not justify a comprehensive ophthalmologic examination or and rarely a Level 4 or 5 Evaluation and Management examination

You are kidding…right?

Misunderstood Concepts

New patient presents with single complaint of an itchy right eye – which of the following are automatically NOT medically necessary?Cover testBinocular assessmentGross visual fieldsInternal, ophthalmoscopic examination

ANSWER: None of them

One of The Biggest MisconceptionsMost doctors think as long as they PERFORMED all the elements, they can bill a high level EM code (IV or V) or comprehensive ophthalmologic code

WRONG!The elements you perform are dictated by the REASON FOR THE VISIT – you cannot “fit” what you do for a patient based on the level of examination you WANT to achieve (“back

coding”)

Disable, de-preference, do whatever you have to do but get rid of the “Coding Tool” in your EMR. CMS 2012/13 Special Audit Project openly states the use of Coding Tools results in intentional up-coding and will be considered suspicious of fraud

Another recommendation...

Per CPT:

“When determining the level of evaluation and management and diagnostic testing necessary for a particular encounter, the

physician’s decision is based on the nature of the presenting problem (also called the

reason for the visit)”

Look…I Didn’t Make This Stuff Up

MINIMAL: An encounter that does not require the presence of a physicianMINOR: A problem that runs a definite and prescribed course, is transient, and is not likely to permanently alter any health statusLOW SEVERITY: A problem where the risk of morbidity without treatment is low and a full recovery without functional impairment is predicted.

CPTs Definitions of “Nature of Presenting Problem”

MODERATE SEVERITY: A problem where the risk of morbidity without treatment is moderate; has an uncertain prognosis and there is an increased probability of prolonged functional impairment and/or mortalityHIGH SEVERITY: Problem where the risk of morbidity and/or mortality without treatment is high and there is a high probability of severe, prolonged functional impairment even with treatment.

CPTs Definitions of “Nature of Presenting Problem”

Wrong…

You have to have a medical reason for the visit

MYTHYou Have to Have Symptoms to Bill for Medical Services

1. Symptoms2. Patient history3. Signs from the examination4. Physician direction5. Request for evaluation of a condition

from the patient or another health provider

#2 & #3 do NOT qualify for Medicare – but do for most any other payor!!

What can qualify as a reason for the visit

Definition (per CPT)“An item or service is considered medically necessary if it is reasonable and necessary in the diagnosis and/or treatment of an illness, injury or defect”

It’s pretty easy – is the conduct of care or results of a test necessary in the care of my patient?

With some exceptions, “rule out” testing not based on clinical signs is consider to be NOT medically necessary

Number Two – Medical Necessity

Medical NecessityThe historical and legal concept of medical necessity states that it can only be determined by the attending physicianPayment PolicyDetermination of benefit is totally the right of the payer – it’s their checkbook.

More recently the terms are being used interchangeably – doesn’t matter. If you consider something to be medically necessary, someone pays for it. Benefits often do not equate with medical necessity!

Confusion

“The medical record must clearly document the medical necessity of the examination and all associated testing and treatment”

And you do that how?Associated reason for the visit (discussed)Complete documentation of findings (obvious)Orders for all diagnostic testsInterpretation and reports for all diagnostic tests

CPT Says What About Medical Necessity

“The medical necessity of the testing must be clear to the auditor based on the documentation”

PROBLEM: Subjective opinion of auditor

SOLUTION: Orders

Testing Orders - Per CPT

Three PlacesPlan of previous visit (not best choice)In the reason for the visitIn an EHR orders section

Ex: “Physician directed examination to monitor glaucoma status – order 24-2 OU”

How To Document Orders

REQUIRED for every diagnostic test Do NOT have to be in a separate chart – just

identifiable away from the main record documentation No direction from CPT on requirements of I/R. Many

suggestStatement of reason for testBrief summary of resultsStatement of reliability of results or patient cooperationHow the results will influence your care of patient

Interpretation and Reports

CPT requires that patient encounters must contain a signature of the examining physician

Although not mandated, could be best if on every page of the examination (easy with most EHRs)

For a paper record, a signature is just that….your written signature – MUST be legible (or claim DENIED!). For that matter, if ALL your written recordings are not legible, claim denied. You need a Signature Page on file!

Last Requirement - Signatures

EHR SignaturesElectronic - “Electronically signed by Joe

DeLoach, OD 9/2/13 4:30pm”Digitized – an actual reproduction of your

manual signature transferred to paperDigital – an encryption or fingerprint that

binds the doctor to the record (not ready for prime time yet!)

Signature Attestation - statement that you performed all the services (far too complex)

No MEDICAL reason for visit – claim deniedReason for the visit not addressed – claim

deniedMedical necessity not documented – claim

deniedNo orders for tests – claim likely deniedNo interpretation and report – claim deniedNo acceptable signature – claim denied

Let’s Summarize What We Know So FarYou get audited by medical payer…

WHAT ELSE?

This one is easy – can’t read it, automatic denial

EXTREMELY difficult audit defense Documentation will be next to

impossible with ICD-10 Please join the 21st Century

Illegible Paper Records

CPT states that on established visits, the history must be reviewed applicable to the reason for the visit. You have two choices:Make changes, if present, to the patient’s history and

hope that an auditor recognizes the changes made (without the previous record? Good luck!)

OrMake a note in your history section that you reviewed

and changed the history where appropriate, and INITIAL it

Unclear Review of History

If the history is brought forward and you make and initial a “reviewed” statement, your level of history is credited as the same as the history you reviewed (even if it is included VERBATUM in the encounter)

The DOCTOR, not the staff must initial the review

EXAMPLE REVIEWED STATEMENT“I have reviewed the patient’s history elements and made changes where appropriate. JWD 1/1/15”

Unclear Review of History

Remember, there are eight of them: Location Quality Severity Duration Timing Context Modifying factors Associated signs and/or symptoms

Unclear or missing HPI Elements

As a rule you always want at least four HPI elements – essential if you want to use E/M

codes

Bonus non-medical claim adviceVision companies, especially the big ones, have

specific requirements for documenting a billable contact lens evaluation. See the next slide for what they are!

Without proper documentation, companies will take back the contact lens fitting fee

One of the companies will take back the contact lens fitting fee AND the money your patient paid out of pocket for contact lens services

Documenting a Contact Lens Evaluation

1. History needs to include type/modality lenses worn, how they are worn, solutions used

2. Examination needs to document the fitting characteristics of the lenses (NOTE: Simply documenting WHAT trial lenses were used is not sufficient – need to note their fit). Also requires Ks and over-refraction

3. The assessment needs to state how the patient is doing with the lenses

4. The plan needs to state what you are doing going forward, even if that is no change

Documenting a Contact Lens Evaluation

VSP and Eyemed are HOT on the audit trail for “medically necessary contact lenses” – average penalties > $50K

Medically necessary contacts are exactly what they have always been – cones, pellucids, high cyl, post surgical follies

Just sayin….A two week disposable daily wear contact lens patient overwears their lenses so you decide to fit them in daily lenses – the daily lenses

are NOT medically necessary

Another side note….

Cited by OIG Work Plan as “significant concern for fraud and abuse”

Templates are completely legal and proper – if used properly

You need to assure that the findings recorded were actually from observations performed THAT VISIT (appropriate findings can look very similar visit to visit – not your fault)

How do you do that?

EHR Template Mis-Use

First of all, by definition, they all are Lack of “except as noted” language No signed review of history OVER or inappropriate documentation of case history

(“over”- really?) Impossible findings (best example – retinal periphery is

stated as normal but patient was not dilated) Diagnosis with no abnormal clinical findings The obvious – EVERY chart looks the same

“Suspicious” Templates

Safest answer….

Make sure that on every visit you have to select to add normative findings

“Suspicious” Templates

Not sure why this would ever be a problem except carelessness

Problem is, an auditor can deny the office visit and any diagnostic tests associated with a diagnosis that does not have associated clinical findings

Diagnosis Without Clinical Findings

CPT coding guidelines dictate that you apply the MOST SPECIFIC diagnosis related to any procedure for which you bill services

“Snapshot in time” Use EYE codes, not systemic codes (except

code first) Do not use unspecified codes (xxx.o or xxx.00

codes – some of most common red flags - 365.0, (this will not be a problem with ICD10!)

Not Using the Most Specific Diagnosis

Dilation is “usually” a requirement of the comprehensive ophthalmologic code (unless contraindicated) and always part of the internal evaluation elements of the E/M codes (NO contraindication statement)

Unless you dilate these patients or state the reason you did not, an auditor can either down-code your examination or deny the office visit all together (usual action)

Not dilating in Comprehensive Visit

Facts2014 CPT is ambiguous – For 92004/14 “usually includes” For E/M codes, VERY clear is required to count internal exam

Opinions Abound CPT has an “unwritten” policy of variance CPT has NO “unwritten” policy of variance Medical payors have an “unwritten” policy of variance

Sorry - no definitive answer. But what is the REAL issue here – the auditor or the judge?

Exceptions?

Vision company audits tend to be less fair and often made up on the spot. If you want to be safe, consider that vision plans will adhere to the CPT definition of a comprehensive ophthalmologic examination and require dilation unless documented as contraindicated

Dilation is usually addressed - how well do you know your vision plans

What About Vision Companies?

VSPDilation required for all diabetic or “at risk” patients (bs…)

EyeMedDilation usually considered part of comprehensive examination. Required for diabetic patients

“Blurred vision” as a sole reason for the visit does not constitute a medical visit unless the reason for the blurred vision is medical

Don’t believe me – call Dr. Craig Thomas and ask him how painful it is to write a check to CMS for $36,000.00

“Blurred vision” as the reason for visit

Doctor - become the coding and documentation expert in your office

Have your medical records audited by a professional company every year (new Fraud and Abuse Compliance requirement!)

Consider outsourcing your billing

“To achieve success, do what you are an expert at and outsource the rest”

Roy Spence Jr

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