Optometry Coding & Billing Alert

Published on Fri Nov 07, 2003 PDF

Question: What risk level does a patient with glaucoma qualify for? I'm having trouble figuring out how glaucoma fits into the medical decision-making component of E/M coding.
    
Wisconsin Subscriber

Answer: The medical decision-making component of an E/M service - straightforward, low, moderate or high - is determined based on the number of possible diagnoses and/or management options present; the amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed; and the level of risk of significant complications, morbidity and/or mortality including comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options.
 
The risk component includes those risks associated with presenting problems, in this case the chronic condition of glaucoma, and diagnostic procedures and management options. The highest level of risk in any of these areas determines the overall level of risk.
 
In the category of presenting problems, if the patient is established and is seen for a return visit and has stable glaucoma and no other problems, the patient is considered to have minimal problems.
 
But if, for example, a patient returns with uncontrolled glaucoma that requires a change of medication, the level of problem is bumped up to low, and this increases your chances of being able to bill a higher-level E/M service.
 
And, if the patient was a new patient, the presenting problem would be considered moderate, as one new problem with no additional workup planned.