Appropriate care, proper coding can maximize reimbursement

Most third-party carriers reimburse significantly more for an intermediate visit compared to an established Evaluation and Management level 3 visit.

Throughout my residency and my several years in private practice it became obvious to me that most of my colleagues do their billing and coding primarily out of habit rather than according to the Current Procedural Terminology guidelines and the 1997 Evaluation and Management guidelines.

Admittedly, the rules governing billing and coding are not always that easy to understand and implement, but coding by habit is dangerous ground to be on in a third-party audit. In addition, proper coding maximizes reimbursement, increases efficiency and, obviously, protects you in an audit.

Perhaps I could generate the same amount of revenue (or more) by seeing 15 patients per day and coding accurately, in comparison to my colleagues who were potentially seeing 30 patients a day but were coding incorrectly. I could provide a higher quality exam, as my time was now divided among fewer patients, or maintain my current volume of patients but make more money by doing the same amount of work.

We have all been warned over the past few years that third-party audits are on the rise. The best defense in a third-party audit is great medical record keeping and a thorough understanding of the rules regarding billing and coding.

Common mistakes

Some practitioners mistakenly believe that if they do every possible test at every visit they can rightfully code at higher levels. This is faulty logic for two reasons: performing additional testing only to code at higher reimbursement levels is unethical and just plain wrong, and all tests performed on a given patient must be based on medical necessity.

A second mistake is making the poor decision to exclusively use Eye/Ophthalmology codes (920x2/920x4) and forgetting about the Evaluation and Management (E/M) codes entirely because it is “easier.”

However, the Eye/Ophthalmology codes themselves do not cover/describe every patient examination an eye doctor will ever encounter. The more accurate, appropriate and financially beneficial way is to use a combination of all of the 92xxx and 99xxx codes in their properly designed manners, based on their definitions and dictated by the content of the patient record that was created in line with the patient encounter and its requirements based on medical necessity.

While most practitioners seem to understand what is needed to perform a comprehensive exam (92004/92014), most have a poor understanding of when to choose between an intermediate visit vs. an E/M level 3 (99213) code. In this article I will focus specifically on the differences between established intermediate services (92012) and established E/M level 3 (99213) visits. I am not suggesting that we choose a particular code purely based on how much it reimburses, but there is nothing wrong with getting paid appropriately for the medically necessary/indicated services we provide for our patients.

Intermediate vs. established E/M level 3

I will highlight some of the important distinctions between the two code sets. An established E/M level 3 (99213) is one of the most common codes used by optometrists for follow-up visits. Choices of E/M codes are based on three zones/areas: case history, exam components and medical decision making. To code at a certain level with established E/M codes, two of the three zones/areas need to be at that level or above. For new E/M codes, three of the three zones/areas need to be at or above that level to code that level. A table of each zone/area required for a 99213 code is provided.

Intermediate services (92002/92012), on the other hand, are more generally defined than E/M codes and are described by Current Procedural Terminology (CPT, American Medical Association) as “an evaluation of a new or established condition complicated by a new diagnostic or management problem not necessarily relating to the primary diagnosis, including case history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy.”

To translate, this means if there are any new management decisions, an intermediate exam would be an appropriate choice as long as all the tests included in the visit are based on what is medically necessary for the patient and all the exam components required for a 92xx2 code are included in the record of that patient encounter. A new management decision could include the need to start a new medication for a new or previous ocular condition or discontinuing one medication and starting another because the first one did not result in an appropriate clinical response or the onset of new symptoms.

However, if at that particular encounter the patient is stable and you are simply continuing the medication or other care regimen because of an appropriate desired effect or simply discontinuing a medication because the ocular condition has resolved as a result of that therapy, an established E/M level 2 (99212) or E/M level 3 (99213) would be more appropriate.

The accompanying table shows the intermediate exam requirements for 92xx2 as per CPT guidelines.

Real-life example: Red eye, foreign body sensation

A new patient presents to your practice with a chief complaint of a “red eye with foreign body sensation that started yesterday.” Your slit lamp exam reveals a small corneal abrasion, which would explain the patient’s chief complaint. Therefore, you start him on artificial tears four to six times per day and topical antibiotic drops four times daily with instructions to return for follow-up the next day. From an intermediate exam viewpoint, the “new or established condition” is the corneal abrasion. The “new management or diagnostic problem” would be starting the patient on a new antibiotic regimen and/or artificial tears to prevent infection and speed up the healing process. Therefore, one of the appropriate code choices based on this example would be a new intermediate service: 92002. It could probably alternatively be coded with one of the 992xx codes.

 

When this patient returns the next day you should charge/bill for a follow-up visit. The patient reports that his eyes are now comfortable, and you find that the corneal abrasion has now resolved fully. You tell the patient to discontinue the antibiotic drops but continue the artificial tears two to four times per day for an additional 1 to 2 weeks. Can we select an intermediate service again in this case? To check ourselves, the “new or established condition” is the corneal abrasion. However, the corneal abrasion is not “complicated by a new management or diagnostic problem” because you are simply discontinuing one medication and continuing the other as the abrasion heals as you expected it to. Because there are no new problems or management decisions, your only option would be one of the established E/M codes (99212 or 99213) depending on your case history, exam components and decision making.

Now assume the patient returns the next day saying he is using his antibiotic drops and artificial tears as directed, but his eye is still bothering him significantly. Upon slit lamp examination you see that the abrasion is not healing as well as you hoped, so you decide to use a bandage contact lens to help with comfort and speed the re-epithelialization of the cornea. In this case, the “new or established condition” is still the corneal abrasion. The “new diagnostic or management problem” would be inserting a bandage contact lens on the abrasion given the decreased rate of healing and the patient’s complaint of eye pain. In this situation I would charge for the bandage contact lens and choose an established intermediate service (92012) based on its definition and exam requirements, assuming all the requirements again have been met from a medically necessary standpoint.

Real-life example: Three-month IOP check

In another example, an established glaucoma patient reports for his 3-month IOP check. Upon presentation and after reviewing the patient’s optic nerve appearance and correlating visual field analysis you find that the patient’s glaucoma is progressing despite relatively good IOP control on a once-a-day prostaglandin analog. You decide that further IOP reduction is necessary, so you add a generic beta-blocker in the morning to further decrease the IOP and tell the patient to return for an IOP check in 2 to 4 weeks. The “new or established condition” in this case is primary open-angle glaucoma (POAG), and the “complicated by a new management or diagnostic problem” is the fact that the glaucoma is no longer stable and requires an additional medication. Therefore, this example would meet the definition of at least an established intermediate service (92012), assuming you have met the other requirements of an intermediate exam, and possibly a higher level 99000 code.

 

When this patient returns for his IOP check, you find that he has no side effects from the medication and the new target IOP has been met. You elect to continue the medication and have the patient return for another IOP check in 3 months. In this second follow-up exam, the “new or established condition” is POAG but it is not “complicated by a new management or diagnostic problem” because you are electing to simply continue the present medications. In this case, you should default to the E/M level 99212 or 99213 codes depending on the rest of the case history, exam components and medical decision making.

Undercoding will reduce potential income

During my residency, my fellow residents and I would see, on average, 20 patients per day through our emergency service alone. For the first half of the year, like many current practitioners and colleagues, most of us defaulted to the E/M level 3 (99213) for most of our established patient encounters. Retrospectively, we found that many of these emergency room (ER) patient exams met the criteria for higher levels 99000 codes or for the 92002-92014 codes.

To put this in perspective, during my residency tenure, there was a $10 difference between our reimbursement for an established E/M level 3 (99213) and the higher paying established intermediate service (92012). Many of the patient encounters qualified for both, but we chose 99213 out of habit and fear of a potential audit. However, if we saw 20 patients a day in the ER (which was a conservative estimate for most days) we were letting a minimum of $200 per day walk out the door. If you multiply $200 per day with a 50-week work year, that turns out to be $1,000 extra per week and $50,000 per year. That is poor business sense for any practicing OD. Imagine if we knew how to accurately use the other available visit codes as well, such as the higher level E/M codes or comprehensive ophthalmological services (92004/92014).

With a working understanding of the codes, you will realize that what the patient needs and what you have carefully recorded in the patient’s record will often translate to a higher level of coding, leading to higher revenue for the practice. There is nothing unethical or fraudulent about getting paid appropriately for the work that is medically necessary to manage our patients.

Disclosure: Borgman has no relevant financial disclosures.