Documentation for Medicare

1. Documentation for Medicare

2. An important consideration when examining patients is the type of insurance coverage; there are two basic types:vision insurancemedical insurance

3. Vision insurance provides reimbursement for periodic eye examinations, and may also include payments, discounts, or allowances for ophthalmic materials (spectacles and contact lenses). Documentation of diagnosis and treatment is refractive in nature.Medical insuranceprovides reimbursement for eye examinations performed out of medical necessity. A medical diagnosis is required (i.e., glaucoma, retinal detachment, cataract).Medicare is a medical insurance program.

4. An essential element of documentation under Medicare is that the history reflect a medical complaint. “General eye examination” (or similar words) is not such a complaint. “Flashes of light” or “diplopia” is a medical complaint. For a practitioner to receive reimbursement under a medical insurance plan, a medical complaint must be documented in the record.

5. Chief ComplaintThe chief complaint should be a short statement (just a few words) that identifies the patient’s presenting medical problem (“blurred vision”, “red eye”). On occasion, when the complaint is unique or clinically revealing, it is good to quote the patient (i.e., “zigzag lights”).If a patient with medical insurance does not present with a medical complaint, it is appropriate to continue with the history and examination to ensure there is no medical problem before recording the visit as one for vision care only.

6. History of Present IllnessDetails of the chief complaint should be documented under the history of present illness (HPI). At least 4 of the 8 possible components of HPI (location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms) should always be included.

7. For example, for a complaint of blurred vision, the HPI could be:“bilateral, constant, VA mildly reduced, for 6 months, gradual onset, at distance, glasses don’t help, worse at night”.

8. Reimbursement by medical insurance will be disallowed if the chief complaint and the diagnosis do not correspond. For example, a patient whose chief complaint/HPI is “severe pain located behind both eyes, noted at awakening and decreasing in intensity during the day for the past week, not diminished with analgesics”, and whose diagnosis is “cataract” does not have a matching complaint and diagnosis.

9. The first diagnosis entered on the examination form should correspond to the chief complaint. For example, a patient who reports burning and occasional itching of 3 months’ duration, worse in the right eye, and who is found to have corneal staining with fluorescein, should be diagnosed with “dry eye” and this diagnosis should be the first listed. Treatment should be appropriately described (i.e., “artificial tears prn” or “sterile ointment hs”).The first diagnosis should be the one that is used for purposes of coding and billing for medical insurance reimbursement.

10. Medical insurance plans such as Medicare have formalized the manner in which medical diagnoses and procedures must be reported by health care providers in order to obtain reimbursement. There are two resources that are used for purposes of billing; one is for diagnoses and the other is for procedures.

11. Medical diagnoses may be found in the federal government’s International Classification of Diseases (ICD) handbook, which is used by the Centers for Medicare and Medicaid Services (CMS) for the Medicare program. The system employs 5 digit codes to represent medical diagnoses, and it is these codes that are reported by providers for purposes of reimbursement.For example, a code of 365.01 means “glaucoma suspect”.

12. Procedural codes are listed in Current Procedural Terminology (CPT), which is published by the American Medical Association. CPT has been adopted by CMS for use in the Medicare program. These 5 digit codes represent the services provided to patients that are reported for purposes of reimbursement. For example, a code of 92083 corresponds to “threshold visual fields”.

13. For a provider to correctly code and bill a Medicare patient, the procedure code (CPT) code must be appropriate for the diagnostic (ICD) code. For example, a patient who presents for treatment of a corneal abrasion and whose examination is given a procedural code for a comprehensive examination would be miscoded if the examination in fact consisted of a history, acuities, and slit lamp evaluation.

14. Diagnostic codes are fairly straightforward, since all that is required is that they be looked up in the CPT handbook. Procedural codes are more complex, because there are two types of procedural codes currently in use, 92000 codes and 99000 codes.

15. There are four general 92000 ophthalmologic service codes:92002 (intermediate examination, new patient)92012 (intermediate examination, established patient)92004 (comprehensive examination, new patient)92014 (comprehensive examination, established patient)A new patient is someone who has not been seen within the practice within the preceding 3 years; thus, a patient who returns 4 years after an examination would be classified as “new” rather than “established”.

16. The 92000 codes are used most often for “routine” examinations—patients covered by vision plans or with no medically-related complaint—but also for patients with complaints that require a comprehensive examination, such as a patient with hypertension but no retinopathy, returning for an annual eye examination.

17. The intermediate examination codes (92002 and 92012) are for the evaluation ofnew or existing conditions, complicated by a new diagnostic or management problem that is not necessarily related to the primary diagnosis.Testing includes history, external and adnexal assessment, and other diagnostic procedures as indicated, including pupillary dilation and evaluation of the interior of the eye, up to 7 exam elements.

18. The comprehensive examination codes (92004 and 92014) are for full evaluations,including history, external, sensorimotor, visual fields (confrontation), and ophthalmoscopic assessments; slit lamp, tonometry, and dilation are usually included, so that there are 8 or more exam elements.Comprehensive examinations always include the initiation of diagnosis and treatment.

19. The 99000 evaluation and management (E/M) codes are used for examinations that are medical in nature because of medical complaints or follow-ups for medical problems. They are not used for “routine” examinations or examinations that are for the correction of visual acuity only.

20. The purpose of E/M codes is to accurately identify for reimbursement the level of services provided to patients; the higher the level of service, the higher the reimbursement.The selection of the proper level of reimbursement is based on 7 components—history, examination, medical decision-making, counseling, coordination of care, nature of the presenting problem, and time—but history, examination, and decision-making are particularly important. They usually determine the level of service provided.

21. There are 5 levels of service, based on whether the patient is “new” or “established”:

22. Definitions for the levels of service have been established by CMS, and providers must understand and adhere to them when submitting claims for reimbursement:

23. If the level of reimbursement exceeds the actual level of service, the provider can be held responsible for the excess amounts paid and be required to forfeit not only the overbilled amounts but also penalties, based on the amounts overpaid.For each level of service there are requirements (components) that must be met with respect to history, examination, and medical decision-making. The CMS has provided guidelines for these three components so that clinicians will understand the testing that must be performed to satisfy them.

24. Part 1--HistoryThere are four levels of history-taking: • problem focused • expanded problem focused • detailed • comprehensive

25. For each level of history-taking, two or more of the following elements must be present: • chief complaint (CC) • history of present illness (HPI) • review of systems (ROS) • past, family and/or social history (PFSH)

26. More history elements are required for higher level E/M services:Problem Expanded FocusedProblem FocusedDetailedComprehensiveCC CC CC CCbrief HPI brief HPI extended HPI extended HPI pertinent ROS extended ROS complete ROS pertinent PFSH complete PFSH

27. History of Present IllnessThe HPI is a chronological description of the development of the illness from the first sign or symptom (or the last examination) to the current examination. The HPI consists of the following elements: • location • quality • severity • duration • timing • context • modifying factors • associated signs and symptoms

28. There are 2 levels of HPI documentation: brief and extended. A brief HPI consists of 1 to 3 of these elements; they should be described in the patient's record. An extended HPI consists of at least 4 elements of the HPI or a description of the status of at least 3 chronic or inactive conditions.

29. Review of SystemsA review of systems (ROS) is an inventory of body symptoms obtained through questions that seek to identify signs or symptoms which the patient has experienced or may be experiencing. A ROS and PFSH obtained at an earlier examination does not need to be reviewed in full; the previous information must be updated, which is achieved by describing any new ROS or PFSH information (or that there has been no change) and noting the date and location of the previous ROS and PFSH information. The ROS and PFSH may be recorded by staff members on a form completed by the patient; there should be a notation (signature) in the record by the provider to supplement or confirm this information.

30. The following 14 systems are recognized: • constitutional symptoms (e.g., fever, weight loss) • eyes • ears, nose, mouth, throat • cardiovascular • respiratory • gastrointestinal • genitourinary • musculoskeletal • integumentary • neurological • psychiatric • endocrine • hematologic/lymphatic • allergic/immunologic

31. There are 3 levels of ROS documentation: problem pertinent, extended and complete.A problem pertinentROS inquires about the system directly related to the problem(s) identified in the HPI. The patient's positive responses and pertinent negative responses for the system related to the problem(s) should be documented.

32. An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional symptoms. The patient's positive responses and pertinent negative responses for 2 to 9 systems should be documented.

33. A complete ROS inquires about the system directly related to the problem identified in the HPI plus all additional body systems. At least 10 organ systems must be reviewed. The systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permitted. In the absence of such a notation, at least 10 systems must be individually documented.

34. Past, Family and/or Social HistoryThe PFSH consists of a review of three areas: • past history (illnesses, operations, injuries and treatments); • family history (medical events in the family, including diseases which may be hereditary or place the patient at risk for disease); • social history (an age appropriate review of past and current activities).

35. There are two levels of PFSH documentation: pertinent and complete.A pertinent PFSH is a review of the history directly related to the problem(s) identified in the HPI. At least 1 specific item from the 3 history areas must be documented.A complete PFSH for in-office services is a review of: • at least 1 specific item from 2 of the PFSH history areas for established patients; • at least 1 specific item from all 3 of the history areas for new patients.

36. Part 2--ExaminationEach level of examination has been defined by CMS:• problem focused--a limited examination of the affected area or organ system;• expanded problem focused--a limited examination of the affected body area or organ system and any other symptomatic or related body area or organ system;• detailed--an extended examination of the affected body area or organ system and any other symptomatic or related body area or organ system;• comprehensive--a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area or organ system.

37. For examination of the eye, one or all of the following elements may be required:• visual acuity (does not include refraction)• confrontation fields• cover test and ocular motility• inspection of bulbar and palpebral conjunctivae• examination of the ocular adnexa (lids, lacrimal glands and drainage, orbits, and preauricular lymph nodes)• examination of pupil and iris (shape, direct and consensual light response, anisocoria, morphology of pupil and iris)• slit lamp assessment of the cornea and tear film• slit lamp assessment of the anterior chamber• slit lamp assessment of the lens• measurement of IOP (except in children, patients with trauma or infectious disease)• dilated fundus examination (unless contraindicated) noting optic disc size, C/D ratio, and appearance, and nerve fiber layer appearance• dilated fundus examination (unless contraindicated) of the retina and vasculature.

38. Thus there are a total of 12 elements identified for the examination of the eye.Requirements for each level of examination are: • problem focused--1 to 5 elements • expanded problem focused--at least 6 elements • detailed--at least 9 elements • comprehensive--all 12 elements, plus at least 1 of the following neurological/psychiatric elements: -- brief assessment of orientation to time, place and person --brief assessment of mood and affect (depression, anxiety, agitation)

39. Part 3--Decision MakingMedical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:• the number of possible diagnoses and/or management options that must be considered;• the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed;• the risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient's presenting problem, the diagnostic procedures and/or the possible management options.

40. There are 4 levels of medical decision-making: • straightforward (SF) • low complexity (LC) • moderate complexity (MC) • high complexity (HC)

41. The elements increase in complexity with higher-level E/M services: Amount and/or Risk of Complications Number of Diagnoses Complexity of and/oror Management OptionsData ReviewedMorbidity or MortalitySF minimal minimal or none minimalLC limited limited low MC multiple moderate moderateHC extensive extensive high

42. E/M codes for services rendered in-office are divided into those for new patients and for established patients (individuals seen within the preceding 3 years). To determine the appropriate E/M code for services requires that the provider consider history, examination and complexity of medical decision-making. To satisfy the requirements for new patients, all 3 elements for a level of service must be met. To satisfy the requirements for established patients, 2 of 3 elements must be met.

43. New PatientsHistoryExaminationDecision Making99201 problem focused problem focused straightforward99202 expanded problem expanded problem straightforward focused focused99203 detailed detailed low complexity99204 comprehensive comprehensive moderate complexity99205 comprehensive comprehensive high complexityEstablished Patients99211 physical supervision none none only 99212 problem focused problem focused straightforward99213 expanded problem expanded problem low complexity focused focused99214 detailed detailed moderate complexity99215 comprehensive comprehensive high complexity

44. Summary of E/M Requirements

45. For next class, answer the 10 problems in your lecture notes, assigning the correct E/M code for each problem.You will earn 10 points of extra credit for doing so!