Documentation for Medicare

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Documentation for Medicare
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An important consideration when examining
patients is the type of insurance coverage there
are two basic typesvision insurancemedical
insurance
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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 insurance provides
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.
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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.
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Chief ComplaintThe
chief complaint should be a short statement (just
a few words) that identifies the patients
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.
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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.
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For example, for a complaint of blurred vision,
the HPI could bebilateral, constant, VA
mildly reduced, for 6 months, gradual onset, at
distance, glasses dont help, worse at night.
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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.
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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.
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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.
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Medical diagnoses may be found in the federal
governments 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.
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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.
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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.
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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.
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There are four general 92000 ophthalmologic
service codes92002 (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.
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The 92000 codes are used most often for routine
examinationspatients covered by vision plans or
with no medically-related complaintbut 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.
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The intermediate examination codes (92002 and
92012) are for the evaluation of new 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.
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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.
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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.
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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 componentshistory, examination,
medical decision-making, counseling, coordination
of care, nature of the presenting problem, and
timebut history, examination, and
decision-making are particularly important. They
usually determine the level of service provided.
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There are 5 levels of service, based on whether
the patient is new or established
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Definitions for the levels of service have been
established by CMS, and providers must understand
and adhere to them when submitting claims for
reimbursement
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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.
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Part 1--HistoryThere are four levels of
history-taking

• problem focused
• expanded problem focused
• detailed
• comprehensive

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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)
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More history elements are required for higher
level E/M servicesProblem
Expanded Focused Problem
Focused Detailed
ComprehensiveCC CC CC
CCbrief HPI brief HPI
extended HPI extended HPI
pertinent ROS extended ROS
complete ROS pertinent PFSH
complete PFSH
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History of Present Illness
The 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
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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.
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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.
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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
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There are 3 levels of ROS documentation problem
pertinent, extended and complete.A problem
pertinent ROS 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.
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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.
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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.
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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).
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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.
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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.
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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.
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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)
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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.
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There are 4 levels of medical decision-making
straightforward (SF) low complexity (LC)
moderate complexity (MC) high complexity (HC)
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The elements increase in complexity with
higher-level E/M services
Amount and/or Risk of Complications Number
of Diagnoses Complexity of
and/or or Management Options Data
Reviewed Morbidity or MortalitySF minimal
minimal or none minimalLC limited
limited low MC multiple
moderate moderateHC extensive extensive high

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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.
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New Patients History
Examination Decision Making99201 problem
focused problem focused straightforward99202 ex
panded problem expanded
problem straightforward focused focused99203
detailed detailed low complexity99204 compreh
ensive comprehensive moderate complexity
99205 comprehensive comprehensive high
complexity
Established
Patients99211 physical supervision
none none only 99212 problem
focused problem focused straightforward99213 ex
panded problem expanded problem low
complexity focused focused99214 detailed det
ailed moderate complexity99215 comprehen
sive comprehensive high complexity
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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!
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