Can Optometrists Sell Over-the-Counter Vitamins



It is incumbent that each doctor of optometry becomes well informed with the codes billed in their office. Frequently reviewing Medicare’s code requirements, attending coding seminars, and reading coding columns in the journals is the best way that a practicing optometric doctor can keep current. This ongoing process should continue on a regular basis. From here on out, it seems that the financial future of doctors of optometry and their coding abilities will be tightly linked.

Medicare billing using the 99201-99215 Codes requires different specific chart documentation based on the patient’s reason for the visit. These codes are for an established patient who has been seen by the office in the past three years.

Established Outpatient: CPT Code 99211

• Key Components Not Required

• Physician Need Not be Present (only supervising)

• E/M Minimal Problem

• Staff Time: 5 minutes

Established Outpatient: CPT Code 99212

• Key Components (2 of 3 meet or exceed requirements)

• E/M Problem Focus History

• E/M Problem Focus Exam

• E/M Straight Forward Medical Decision

• E/M Self Limited or Minor Problem

• Physician Time: 10 minutes

Established Outpatient: CPT Code 99213

• Key Components (2 of 3 meet or exceed requirements)

• E/M Expanded Problem Focused History

• E/M Expanded Problem Focused Exam

• E/M Low Complexity Medical Decision

• Problem Severity

• E/M Low Severity Problem

• E/M Moderate Severity Problem

• Physician Time: 15 minutes

Established Outpatient: CPT Code 99214

• Key Components (2 of 3 meet or exceed requirements)

• E/M Detailed History

• E/M Detailed Exam

• E/M Moderate Complexity Medical Decision

• Problem Severity

• E/M Moderate Severity Problem

• E/M High Severity Problem

• Physician Time: 25 minutes

Established Outpatient: CPT Code 99215

• Key Components (2 of 3 meet or exceed requirements)

• E/M Comprehensive History

• E/M Comprehensive Exam

• E/M High Complexity Medical Decision

• Problem Severity

• E/M Moderate Severity Problem

• E/M High Severity Problem

• Physician Time: 40 minutes

These codes appear to be very specific, but the practitioner really needs to know the meaning of what constitutes a “Problem Focused History” or what elements establish a “Detailed Exam” or what exactly is a “High Level of Decision Making.” How to use these elements of the 99xxx are usually found in the front of all coding books. The doctor of optometry will need to review the coding requirements frequently to avoid coding errors.

There are several things you can do to minimize your chance of an audit:

• First, make sure you don’t make errors on your claim forms. The most common errors are missing information, not signing the form, wrong combination of codes, not collecting deductible and missing NPI numbers. Too many of these types of erroneous claims filed could indicate to Medicare that the doctor either doesn’t know what he or she is doing or isn’t properly reviewing the claim before submission.

• Another reason for audit would be that the doctor is billing out of the norm compared to other practices in his or her area. Medicare has established coding patterns for optometry using the 99xxx codes. They know, for example, that depending on the location of a practice in California, in coding the 99211-99215 Codes, approximately 60 percent of the time a doctor of optometry will use the 99213 Code. They also know that the 99212 and the 99214 are used about 15-18 percent each, and the 99201 and the 99215 Codes are used respectively about 2 percent. Too many claims that fall out of the norms are red flags to Medicare, which could trigger an audit.

• Chart documentation is really the key to good coding. Medicare wants the doctor of optometry to only code and bill at the level that the documentation proves, no more and no less. As far as Medicare is concerned, both under coding and over coding a claim can show elements of fraud. Unscrupulous practitioners sometimes will under code a claim to give discounts to their patients. On the other hand, over coding the bill is a way for a dishonest clinician to receive unearned income from Medicare billing. Consequently, the doctor of optometry needs to take care that the chart documentation matches the coding level.

• Experts say that as a reference, the amount of chart documentation using the E/M new patient codes, 99201-99205, goes up as the codes get more complex. The 99213 Code requires about one full page of documentation; 99214 needs one-and-a-half to two pages and 99215 involves three or more pages of documentation to properly bill.

• A large part of the reimbursement associated with a code depends on the Medical Decision Making component. Documentation in the chart should make it clear as to how your medical decisions in treating the patient are made. Because of standard defaults, along with “yes and no” check boxes in some EHR programs, the pathway to the medical decision-making is not always clearly shown. Upon audit, Medicare could down code this chart to a lower billing level. To offset this effect, experts recommend that practitioners override some of the defaults and insert additional notes as needed.

Audits are part of living with insurance billing. Your chart documentation is all that you have in proving and defending what you code and what you bill.

Note: The above information is provided for informational purposes only. It is not intended to replace the professional advice of legal counsel.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download