By Gabbi Gifford, CPC, CDEO, CPMA, CRC, philomathcoding.com
With spring comes beautiful blooms, the buzz of bees and, of course, allergens. An increase in patients flood optometry offices with red, itchy eyes and a chief complaint of allergies. The simplest of mistakes leads to denials which means delayed payment or even no payment at all for the work put in with the patient. Each piece of the puzzle of the revenue cycle works together to ensure proper and timely payment. These puzzle pieces are not limited to the billing, but include the documentation, the coding that matches the documentation of services provided, proper diagnosis code assignment and accurate billing.
DOCUMENTATION
Receiving accurate reimbursement begins at the provider’s documentation. Physicians may not always realize the importance of documentation, but payers pay close attention to all details when performing an audit on a practice. Documentation should always include history, exam, assessment and plan. If the patient has had allergy testing and reports specific allergens, this should be documented. Document the review of this data as well as its source and date. Every problem addressed should have a status and a plan documented. Note that just because there are details that should be specified, the encounter note does not have to be long.
Including symptoms and known triggers such as redness, itching, watery eyes, light sensitivity, etc. in documentation further supports the final diagnosis. Known triggers such as pollen, pet dander and dust mites should also be in the encounter note. How long has the problem been exacerbated? Duration and severity help add to the patient’s overall complaint. The condition treatment should be noted in the Assessment and Plan portion of the encounter note. These details paint the full picture of the problem, the data reviewed and the risk of the patient.
CODING
Diagnosis Codes
Coding…something that can be so intimidating to many providers. For allergies, the diagnosis codes can really be made simple. Is it allergic conjunctivitis or allergic rhinitis affecting the eyes? The ICD-10-CM (diagnosis) codes need to specify whether chronic or acute in regards to allergic conjunctivitis. Especially in eye care, laterality is so important. Unspecified codes should be avoided as it can be a red flag and trigger an audit.
Eyecare diagnosis codes are typically in the H category of ICD-10-CM. The following is a short list of the most common allergy eye codes:
- 1- Acute allergic conjunctivitis
- 1–Right eye
- 2–Left eye
- 3–Bilateral
- 44 Vernal conjunctivitis
- 45 Other chronic allergic conjunctivitis
- 1 Allergic rhinitis due to pollen
- 2 Other seasonal allergic rhinitis
Procedure Codes
The most common procedure code that is billed for addressing allergies is the standard range of Evaluation & Management (office) visits (99202-99215). What is the condition addressed at the time of the visit? Is it a chronic, exacerbated condition? You may be looking at a Moderate level of “problems addressed.” Reviewing external physician notes, allergy testing reports, and other data, count towards your level of MDM. Any ordered tests or tests results reviewed must be something that you are not being reimbursed for separately in order to count towards your MDM.
Finally, we get to the risk. If the provider believes that a patient is at moderate risk, they should explain why in the documentation. If medication is prescribed, not over the counter medications, then it is a Moderate in the “Risk” column. These are purely examples given in the risk column. The clinical provider determines the level of risk of morbidity and/or mortality from their professional perspective.
BILLING
Finally, it is time to bill the services to the payer. The provider or coder/biller should be sure the diagnosis codes are to the highest level of specificity the provider can determine. Modifiers such as -RT, -LT, and -50 (bilateral) should be appended to indicate which eye when treating an issue with a procedure where laterality is specified. Diagnoses and procedure codes should be matched appropriately to lower the chance of denial.
Delayed payments, denials, and audits can be reduced if providers focus on patient care, which involves proper documentation, coding and billing. The office staff can aid in the coding and billing, but ultimately the optometrist is the clinician working with the payer. There is a higher risk of these more minor and lower reimbursed codes falling through the cracks than a higher paying procedure. While they may not amount to higher payments, they add up and can heavily affect a practice’s financial future. Protect the practice by documenting thoroughly. It is not always, “If you did not document it, it did not happen.” Rather, it is, “Document the work to get reimbursed for all that was done.” In the end providers, coders, billers, and even payer auditors want to ensure that it is accurate to provide the total package of good patient care.
