Ophthalmology and Optometry Coding Alert

Make sure you know how to apply V codes Choosing the right CPT procedure code is the first step to ensure your ophthalmologist gets paid for the work he does, but if you fail to attach the correct diagnosis code, you may be in jeopardy of receiving denials. Follow these recommendations to ensure you're properly coding patients' signs, symptoms and diagnoses. Watch for Fourth- and Fifth-Digit Requirements Correct coding requires that you code to the highest specificity possible. That means that your physician should assign the most precise ICD-9 code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient's condition.
 
"Using the fourth or fifth digit when it is required--or just when you do have that information--is an important concept to follow," says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she adds. Pitfall: Just because you have to code to the highest specificity, that doesn't mean you can fill in or assume any information that isn't in the patient's medical record. Don't Avoid Signs and Symptoms When your ophthalmologist provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If, however, the ophthalmologist cannot document a definitive diagnosis, report the patient's signs and symptoms to support medical necessity for services the physician provided.
Avoid "rule-outs": ICD-9 coding guidelines state that you should not report "rule-out" diagnoses in the outpatient setting. You'll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms your ophthalmologist will still get paid for his services, even if he cannot establish a definitive diagnosis. "Look to see if the physician has given the patient a definitive diagnosis," says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. " 'Rule-out,' 'suspected,' 'probable,' or 'questionable' are not codable. If there is no definitive diagnosis given, look for any signs or symptoms that the patient has been having." Example: A primary-care physician sends a patient to your ophthalmologist because he's having headaches and eye pain. The ophthalmologist does not determine a definite diagnosis of an eye problem. "That is a good time to use signs and symptoms," says Brenda Arendt, CMC, of the Center for Total Eye Care in Westminster, Md. In this case, you should report diagnosis code 379.91, (Unspecified disorder of eye and adnexa; pain in or around eye) for the generalized eye pain and 784.0 (Headache) for the headache. Note that some payers don't have 784.0 listed [...]