Medical Coding and Documentation: What Every Doctor Needs to Know!
Richard Soden, OD, FAAO; Michael J. McGovern, OD, FAAO
This course will provide a review of the necessary knowledge base required for proper
documentation and coding of records in the optometric office. Recent updates and changes
in Medicare, coding guidelines and Pay-For-Performance will also be discussed.
Introduction and Course Goals
I.
The Importance of an Appropriate Case History
A. Case History will be reviewed from a proper documentation standpoint, as well as a
coding standpoint
II. Which Examination Codes Do I Choose?
A. Review of the differences between the various sets of codes
1. 92000 series of codes
a. Initial patient encounter
i. 92002 vs. 92004
ii. Documentation requirements
b. Established patient encounter
i. 92012 vs. 92014
ii. Documentation requirements
2. 99000 series of codes
a. Initial patient encounter
i. 99201 through 99205
b. Established patient encounter
i. 99211 through 99215
c. Areas of documentation
i. History
ii. Physical Exam
iii. Medical Decision Making
d. History
i. History of Present Illness (HPI)
1. Physician must personally complete/record
2. Required by all E&M codes
3. Eight elements (see Table A)
a. Brief: 1-3 elements
b. Extended: 4 or more elements
ii. Review of Systems (ROS)
1. No standard ROS for optometrists
2. Fourteen systems commonly reviewed (see
Table B)
a. Problem Pertinent: 1 element
b. Extended: 2-9 elements
c. Complete: 10-14 elements
iii. Past (medical), Family and Social History (PFSH)
1. Past medical history
a.
b.
c.
2. Family
a.
e.
f.
Prior illness, surgery, injury
Current medications
Allergies
History
Health status of parents, siblings,
children
b. Diseases in family that are hereditary
3. Social History
a. Marital status
b. Employment / occupational history
c. Use of drugs / alcohol / tobacco
d. Other social factors
4. Coding Requirements
a. Pertinent: at least one item from any
of the 3 components
b. Complete:
i. At least one item from 2 of the
3 components for following
E&M categories: established
office patient, established
home care patient, subsequent
nursing facility
ii. At least one item from 3 of the
3 components for the following
E&M categories: new office
patient, new home care
patient, consultations
iv. Determining Level Of History
1. See Table C
Physical Exam
i. Twelve physical exam elements (see Table D)
ii. Two brief assessments of mental status
1. Orientation to time, place, person
2. Mood and affect
iii. Determining Level of Physical Exam
1. Problem Focused: 1 -5 elements
2. Expanded Problem Focused: 6 – 8 elements
3. Detailed: 9 – 13 elements
4. Comprehensive: All 14 elements
Medical Decision Making (MDM)
i. Can be difficult to determine – use preferred practice
recommendations (e.g. AOA’s Clinical Practice
Guidelines)
ii. Level of complexity determined by 3 factors:
1. Number of possible diagnoses / treatment
options
a. Minimal
b. Limited
c. Multiple
d. Extensive
2. Amount and complexity of data to
acquire/review
a. Minimal or none
b. Limited
c. Moderate
d. Extensive
3. Risk of complications, morbidity and/or
mortality
a. Minimal
b. Low
c. Moderate
d. High
iii. Determining Level of MDM
1. See Table E
g. Determining Category of Service / E&M Code
i. New patient (see Table F)
ii. Established patient (see Table G)
iii. Consultation (see Table H)
3. The future of consultation codes
4. S codes
a. Routine care vs. medically necessary care
b. S0620 & S0621
i. Documentation requirements
III.Specialty Exam Codes
A. Nursing home codes
1. Nursing facility services
2. Initial service codes
3. Subsequent service codes
B. Surgical codes
1. A review of the most common surgical codes used by optometrists
2. General philosophy of billing surgical codes
IV. Special Ophthalmologic Procedures
A. Review of the documentation and coding guidelines for commonly performed
procedures
1. Refraction
2. Gonioscopy
3. Visual fields
4. Extended and subsequent ophthalmoscopy
5. Photography
6. Corneal topography
7. Scanning laser
8. Report and interpretation
V. Diagnosis Codes (ICD-9)
A. New trends
B. Importance of accurate selection of codes
C. Diabetic coding
D. Preparing for ICD-10
VI. Place of Service Codes
A. Review of the most common place of service codes used by optometrists (see Table I)
VII.
Common Modifiers
A. Review of the most common modifiers used in optometric coding (see Table J)
VIII.
Medicare Changes for 2010/2011
A.
B.
C.
D.
E.
F.
G.
Fee schedule changes
New deductible
National Policy Determinations
Local Carrier Determinations
Carrier changes
Medicare website
855 update - PECOS
Table A
HPI – Elements to Describe Complaint
Location
Duration
Quality
Context
Table B
Severity
Modifying factors
Timing
Associated signs/symptoms
ROS – Commonly Reviewed Systems
Respiratory
Cardiovascular
Muscoskeletal
Hematologic/Lymphatic Ears/Nose/Throat
Psychiatric
Constitutional
Table C
Endocrine
Gastrointestinal
Genitourinary
Integumentary
Neurological
Allergic/Immunologic Eyes
(2 brief assessments
of mental status)
E&M Coding – Determining Level of History
HPI
ROS
PFSH
Problem Focused
Brief
N/A
N/A
Expanded Problem Focused
Detailed
Brief
Extended
Problem Pertinent
Extended
N/A
Pertinent
Comprehensive
Extended
Complete
Complete
Table D
Physical Exam Elements
Visual acuity
Gross visual field testing
Ocular motility
including primary gaze
Conjunctiva
(bulbar/palpebral)
Ocular adnexae
Pupil / iris
Cornea
Anterior chamber
Crystalline lens
Intraocular pressure
Optic disc (dilated)
Posterior segment (dilated)
Table E
Determining Level of Medical Decision Making
Straightforward
Low Complexity
Number of possible
diagnoses / treatment
options
Amount and
complexity of data
Minimal
Risk of complications,
morbidity and/or
mortality
Table F
High Complexity
Limited
Moderate
Complexity
Multiple
Minimal or none
Limited
Moderate
Extensive
Minimal
Low
Moderate
High
Extensive
Determining Category of Service – New Patient
**Must meet or exceed 3 of 3 in the column**
History
Physical Exam
MDM
99201
99202
99203
Problem
Expanded PF
Detailed
Focused (PF)
Problem
Expanded PF
Detailed
Focused (PF)
Straightforward Straightforward Low
Complexity
Table G
99204
99205
Comprehensive Comprehensive
Comprehensive Comprehensive
Moderate
Complexity
High Complexity
Determining Category of Service – Established Patient
**Must meet or exceed 2 of 3 in the column**
99211
History
N/A
Physical Exam
N/A
MDM
N/A
99212
99213
Problem
Expanded PF
Focused (PF)
Problem
Expanded PF
Focused (PF)
Straightforward Low
Complexity
99214
Detailed
99215
Comprehensive
Detailed
Comprehensive
Moderate
Complexity
High Complexity
Table H
Determining Category of Service – Consultation
**Must meet or exceed 3 of 3 in the column**
99241
99242
99243
Problem
Expanded PF
Detailed
Focused (PF)
Problem
Expanded PF
Detailed
Focused (PF)
Straightforward Straightforward Low
Complexity
History
Physical Exam
MDM
Table I
99244
99245
Comprehensive Comprehensive
Comprehensive Comprehensive
Moderate
Complexity
High Complexity
Commonly Used Place of Service Codes
Place of Service Code
Place of Service Name
11
Office
12
Home
13
Assisted Living Facility
14
Group Home
Place of Service Description
Location, other than a hospital, skilled
nursing facility (SNF), military treatment
facility, community health center, State
or local public health clinic, or
intermediate care facility (ICF), where
the health professional routinely
provides health examinations, diagnosis,
and treatment of illness or injury on an
ambulatory basis.
Location, other than a hospital or other
facility, where the patient receives care
in a private residence.
Congregate residential facility with selfcontained living units providing
assessment of each resident’s needs
and on-site support 24 hours a day, 7
days a week, with the capacity to deliver
or arrange for services including some
health care and other services.
A residence, with shared living areas,
where clients receive supervision and
other services such as social and/or
behavioral services, custodial service,
and minimal services (e.g. medication
administration).
21
Inpatient Hospital
22
Outpatient Hospital
24
Ambulatory Surgical Center
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
A facility, other than psychiatric, which
primarily provides diagnostic,
therapeutic (both surgical and nonsurgical), and rehabilitation services by,
or under, the supervision of physicians
to patients admitted for a variety of
medical conditions.
A portion of a hospital which provides
diagnostic, therapeutic (both surgical
and non-surgical), and rehabilitation
services to sick or injured persons who
do not require hospitalization or
institutionalization.
A freestanding facility, other than a
physician's office, where surgical and
diagnostic services are provided on an
ambulatory basis.
A facility which primarily provides
inpatient skilled nursing care and
related services to patients who require
medical, nursing, or rehabilitative
services but does not provide the level
of care or treatment available in a
hospital.
A facility which primarily provides to
residents skilled nursing care and
related services for the rehabilitation of
injured, disabled, or sick persons, or, on
a regular basis, health-related care
services above the level of custodial
care to other than mentally retarded
individuals.
A facility which provides room, board
and other personal assistance services,
generally on a long-term basis, and
which does not include a medical
component.
34
Hospice
A facility, other than a patient's home,
in which palliative and supportive care
for terminally ill patients and their
families are provided.
54
Intermediate Care
Facility/Mentally Retarded
A facility which primarily provides
health-related care and services above
the level of custodial care to mentally
retarded individuals but does not
provide the level of care or treatment
available in a hospital or SNF.
Table J
24
25
50
51
52
55
79
GW
RT / LT
E1/E2/E
3/E4
Commonly Used Modifiers
Unrelated evaluation and management service by the same physician during a postoperative period
Significant, separately identifiable evaluation and management service by the same physician on the
day of a procedure
Bilateral procedure performed at the same session on an anatomical site
Multiple surgeries performed on the same day, during the same surgical session
Reduced service reports a partially reduced or eliminated service or procedure
Indicates a physician, other than the surgeon, is billing for part of the outpatient postoperative care
Unrelated procedure by the same physician during the post-operative period
Service not related to the hospice patient’s terminal condition
Right / Left
E1 = upper left eyelid
E2 = lower left eyelid
E3 = upper right eyelid
E4 = lower right eyelid