Ophthalmology and Optometry Coding Alert

4 steps help you fight downcoding by assessing medical decision-making

If you underestimate your ophthalmologist's medical decision-making, you might report a level-three E/M when he actually performed a level-four - that's a loss of about $43 for a new patient visit and $33 for an established patient visit. Problem: You must evaluate three components - history, exam and medical decision-making - before you can select the appropriate E/M code. The E/M's history and exam components are generally easy to assess from the physician's documentation. When physicians come to the medical decision-making component, however, they often rule out diagnoses, evaluate complicating factors and choose care management options without documenting everything in the patient's chart, says Curt Udell, CPAR, CPC, CMPA, senior advisor at Health Care Advisors Inc. in Annandale, Va. This lack of simple information makes selecting a code difficult for coders.

Solution: CPT lists four levels of decision-making: straightforward, low complexity, moderate complexity and high complexity. You must consider three elements when you evaluate the physician's level of decision-making:    the number of diagnoses or management options
   the amount and/or complexity of data to be reviewed
   the risk of complications and/or morbidity or mortality. These three elements have certain requirements to meet in order to qualify for each of the four different levels of decision-making. Many CPT manuals outline these requirements in Table 2 in the Evaluation and Management Services Guidelines. To qualify for a given level of decision-making, the physician must meet or exceed the requirements for two of the three elements, CPT states.

You can accurately assess the level of decision-making if you find a description of the patient's condition in the physician's chart, inform your physicians of necessary documentation tips, and familiarize yourself with the three elements of decision-making outlined in CPT's Table 2, titled "Complexity of Medical Decision- Making." Follow four steps for success: 1. Look for a description of the patient's condition(s) in the documentation that will indicate the status and seriousness of the diagnosis. Simple, one-word descriptors such as "stable," "worsening" or "new" may be all you need to discern how time-consuming and serious a patient's condition is, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. New or worsening conditions typically involve more time and decision- making, whereas stable conditions involve less decision- making and time on the ophthalmologist's part.

For example: Your ophthalmologist documents an established patient who presents for follow-up of diabetic retinopathy - 362.01 (Background diabetic retinopathy) or 362.02 (Proliferative diabetic retinopathy). The ophthalmologist states, based on examination or testing, that the condition is "worsening." The term "worsening" implies that the physician must review more data, consider more management options and evaluate more risk [...]