Joe W. DeLoach, OD, FAAO
Optometric Business Solutions
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.
No…it is not and
never was
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!)
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!)
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
 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?
New patient presents with single complaint of an itchy
right eye – which of the following are automatically NOT
medically necessary?
 Cover test
 Binocular assessment
 Gross visual fields
 Internal, ophthalmoscopic examination
ANSWER: None of them
Most 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
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)”
MINIMAL: An encounter that does not require the
presence of a physician
MINOR: A problem that runs a definite and
prescribed course, is transient, and is not likely to
permanently alter any health status
LOW SEVERITY: A problem where the risk of
morbidity without treatment is low and a full
recovery without functional impairment is predicted.
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 mortality
HIGH 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.
Wrong…
You have to have a medical reason
for the visit
1.
2.
3.
4.
5.
Symptoms
Patient history
Signs from the examination
Physician direction
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!!
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
Medical Necessity
The historical and legal concept of medical necessity states
that it can only be determined by the attending physician
Payment Policy
Determination 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!
“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 tests
 Interpretation and reports for all diagnostic tests
“The medical necessity of the testing must be
clear to the auditor based on the
documentation”
PROBLEM: Subjective opinion of auditor
SOLUTION: Orders
Three Places
 Plan of previous visit (not best choice)
 In the reason for the visit
 In an EHR orders section
Ex: “Physician directed examination to monitor
glaucoma status – order 24-2 OU”
 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
suggest




Statement of reason for test
Brief summary of results
Statement of reliability of results or patient cooperation
How the results will influence your care of patient
 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!
EHR Signatures
 Electronic - “Electronically signed by Joe DeLoach,
OD 9/2/13 4:30pm”
 Digitized – an actual reproduction of your manual
signature transferred to paper
 Digital – 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 denied
 Reason for the visit not addressed – claim denied
 Medical necessity not documented – claim denied
 No orders for tests – claim likely denied
 No interpretation and report – claim denied
 No acceptable signature – claim denied
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

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!)
Or
 Make a note in your history section that you reviewed and
changed the history where appropriate, and INITIAL it
 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”
Remember, there are eight of them:
 Location
 Quality
 Severity
 Duration
 Timing
As a rule you always want
at least four HPI elements
– essential if you want to
use E/M codes
 Context
 Modifying factors
 Associated signs and/or symptoms
 Bonus non-medical claim advice
 Vision 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
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
 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
 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?
 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
Safest answer….
Make sure that on every
visit you have to select to
add normative findings
 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
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!)

 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)
Facts
 2014 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?
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
VSP
Dilation required for all diabetic or “at risk” patients
(bs…)
EyeMed
Dilation 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
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