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Expert tackles examination component of evaluation and management coding
Part 2 of this three-part series looks at comprehensive ophthalmic exams, required elements and documentation, and other topics.
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 Riva Lee Asbell |
We continue our series on the Documentation Guidelines for Evaluation and Management Coding with questions and answers on the second key component of evaluation and management (E/M) coding — examination.
Q: How many elements actually comprise a comprehensive ophthalmic examination, and why are there so many conflicting answers regarding the number of elements in a comprehensive exam?
A: If you read the original documentation guidelines, there is a chart that lists the components of single organ system eye examination. At the end is a chart to be used for gauging the level of the exam. Count the bullets: There are 14. Thus, 14 elements make up a comprehensive exam.
One of the areas causing this confusion is the elements listed under “Neurological/Psychiatric,” and this stems from there being no shaded border around the box that contains the elements, whereas the section containing the elements for “Eyes” has a shaded border.
The instructions for comprehensive exam state that you should, “Perform all elements identified by a bullet; document every element in a box with a shaded border and at least one element in a box with an unshaded border.” This means for the Neurological/Psychiatric elements, you must perform both but only have to document one element.
Q: Please explain what needs to be checked and what needs to be documented regarding the mental status assessment.
A: There are two bulleted elements under “Neurological/Psychiatric,” namely, (1) Orientation of time, place and person, and (2) Mood and affect (eg, depression, anxiety, agitation). Both of the bulleted items must be performed when doing a comprehensive E/M examination, but only one needs to be documented as a minimum. I recommend performing and documenting both just to avoid any audit problems and to make it simpler.
Q: What constitutes “contraindication” for dilation? If the patient is driving and cannot be dilated but optic nerves and maculae are examined, does this count?
A: Contraindication, for the most part, refers to a medical contraindication, and driving generally would not be considered such. Examples that would be valid include allergies to the dilating drops and head trauma in which dilation would interfere with neurological evaluation. If a patient refuses dilation, it should be documented.
If the posterior segment examination is performed without dilation and there is no medical contraindication, then the two elements (posterior segment and optic discs) cannot be counted toward the level of the exam.
Q: In documenting the required elements of an eye exam (lids and adnexa, pupils, etc.), must each element be listed separately or can I use a phrase such as “normal slit lamp examination including conjunctiva, tear film, cornea, anterior chamber and iris?” Must I note that each element is normal (ie, conjunctiva = normal, cornea = normal, etc.)?
A: Certain elements are required to be performed with a slit lamp, including cornea, anterior chamber and lens. As long as each element is individually addressed, it is considered as having been performed. The documentation may be formatted in an electronic medical record, a forced entry paper form or a narrative. A phrase is sufficient, but each element must be addressed separately in the phrase.
Q: I notice on the elements of examination, under “examination of ocular adnexa,” that preauricular nodes are included. Should we be checking nodes on all patients or just on patients with conjunctivitis symptoms?
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A: Any item that follows the word “including” is a component of that element and must be performed in order for that element to be counted as having been performed. However, each individual component of the element does not have to be documented individually if all components are normal. It would suffice, for example, to state for lids and adnexa that all components are normal.
Once an element is noted to be abnormal, the description of the abnormality must be documented.
Q: If our database includes psychiatric information, does this cover the “Neurological/Psychiatric” bullet needed for comprehensive documentation requirements?
A: If by database you mean the “History” form, the answer is no. This is a requirement under examination for the performance of evaluation of these two elements; the requirement under History is for the inventory of organ systems. I often find when auditing charts that the Neurological/Psychiatric elements are placed on the chart in the History section. Rather, this is considered part of the physician work and needs to be under the Examination section.
Q: With respect to “Elements of examination,” there are no bullets for color vision testing or for stereoscopic circle testing. Can I assume that these two tests do not need to be included as one of the elements for documentation, particularly for a new patient comprehensive examination?
A: Yes, that is correct.
Q: Is it acceptable to use a special ophthalmology procedure code, such as ophthalmoscopy or gonioscopy, in conjunction with an E/M code? Does the finding have to be abnormal to use these codes? For example, a patient is seen after blunt trauma to the eye. Extended ophthalmoscopy is indicated and performed, but it is normal. Is it OK to submit for it if a normal fundus diagram is drawn?
A: The special ophthalmological services may be performed and billed for in addition to the ophthalmology codes or E/M codes as long as there is medical necessity for performing the tests. The findings may be normal. Keep in mind that the extended ophthalmoscopy codes were designed basically for use in retinal work and have some glaucoma application. If the same information can be gleaned without it, it would be excessive to bill it.
Q: With regards to the eye examination, is it OK to document only one aspect for a given element? For example, would it suffice to document that the pupils are round? Or must the chart document the pupil size, shape, direct/consensual reaction and morphology?
A: In my opinion, the best way to document pupils is to perform the examination and use one of the standard nomenclatures as “PERRLA” (pupils equal round reactive light accommodation) unless there is some pathology, which should then be noted and size should be documented. Just noting that the pupils are round would not be sufficient. There are further requirements, such as examination of the irides, that must be performed and documented in that element.
Q: The following elements are prefaced by the phrase “slit lamp examination of:” cornea, anterior chamber, lens. What happens if it is not possible to use the slit lamp, such in the case of extreme trauma?
A: In such instances, Medicare will accept a written documentation of why the slit lamp was not used. In the end, if you cannot perform an element because of the condition, be sure to note that properly.
Q: If I cannot measure the IOP due to a corneal problem or trauma, how do I note that?
A: This is the same as the previous question – just note why the pressure could not or is not being taken. Never skip an element without noting why it was not performed.
Q: What should I do about confrontation visual field documentation? It seems silly and unnecessary to do confrontation fields on patients being followed with automated perimetry.
A: Note in the chart that the patient is being followed with automated perimetry and check with your Medicare carrier if this is acceptable. Most carriers will accept this.
For more information:
- Riva Lee Asbell can be reached at www.rivaleeasbell.com.
- CPT codes, copyright 2008, American Medical Association.