Heads up! 2012 is just around the corner

November 21, 2011

Edited by Chuck Brownlow, O.D., Medical Records consultant

You’ve got just over a month to get ready for a brand-new year in practice. It’s a pretty exciting time for most of us… “Out with the old, in with the new,” “ Turning over new leaves” and all that kind of stuff. If you are at all like me though, much of the old will still be around come next April, and a lot of old habits and issues will be still be cluttering up the office.

In spite of that forecast of likely reality, here are a few things for you to consider.

First, it’s a great time for you to take a look at your current fee schedule and decide whether the fees you are charging match your feelings of the values of your services. It is up to you, after all, to establish fees that you feel are appropriate, totally separate from what Medicare or other insurers pay. Your fees should be unique to your practice, based on your cost of doing business, your market pressures, your education/training/experience, etc. Payers will tell you how much they are willing to pay. It’s up to you to tell all patients what you believe you are worth.

Second, it’s time to review your protocols for providing care, including the way you collect data, the way you decide which tests to do for each patient, the way you keep records of each visit and each procedure, the way you record your diagnoses and management options for each patient, writing orders for returns to office, additional testing, etc., your method for creating interpretations and reports for each procedure that you do, and the way you choose diagnosis, office visit, and procedure codes to accurately communicate to the patient and payer exactly what you did.

The AOA provides lots of assistance in this department. You may refer to www.aoa.org/coding to find a wide variety of tools that you may use. You might also refer to www.aoa.org/x4813.xml to find the whole series of AOA Optometric Clinical Practice Guidelines, created to provide assistance in customizing examinations for various common eye conditions. Another resource you’ll find on the Web site is a list of archived webinars on a host of topics related to medical records and coding. The quickest path to the webinars is www.aoa.org/coding.

Third, it’s time to learn from other doctors’ experience with recent Medicare and commercial insurer audits of eye care records and billing. Much of what happens in an audit consists of a review of a doctor’s compliance with the national rules and customs relative to medical record keeping. All of this is especially important if you are a new user of electronic health records (EHR) or if you are contemplating purchasing and utilizing EHRs in your practice. EHRs let you gather lots of data very quickly and accurately, which may result in higher codes than you are used to seeing. It’s critical that the codes are accurate, high or low, based purely upon the content of the medical record, which in turn is based purely upon the needs of the patient.

All of this requires some introspection on the part of every health care provider and possibly a renewed commitment to the following caveats of good health care:

  • Carefully interview patients to learn why they are in the office (chief complaint/reason for visit)
  • Design the case history and physical examination to match the needs of the patient, customizing as you gain more information throughout the history and examination
  • Provide the care the patient needs that day, no more, no less
  • Keep a detailed, accurate record of all that is done during the visit, being careful to do only the tests that are necessary for that patient, that day, and to record only data that was actually done that day… Avoid automatically populating fields of the medical record from data gathered at an earlier visit
  • Choose the diagnosis codes (ICD-9)  that are germane to the visit; not a list of all diagnoses the patient has (related to the visit or not), or every diagnosis the patient has ever had
  • Choose office visit and procedure code according to the rules and definitions in Current Procedural Terminology (CPT).  

One comment

  1. How can I record on insurance form the new stage codes for glaucoma along with the base glaucoma codes?

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