By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
June 6, 2018
In April 2018, the AOA updated its white paper entitled Vision Therapy and Neuro-Rehabilitation: Optometric Considerations in Third Party Reimbursement. There are important lessons in this document for everyone. We are going to highlight five of these lessons.
The document states “An important consideration of managing a … practice is to appropriately code for all patients, whether using insurance or not.” This is an important concept. It has two supporting background ideas: (1) it is the doctor’s responsibility to code and (2) it is a good practice to code every patient.
In an audit it is unacceptable to try to blame staff for coding mistakes since the doctor is responsible for coding. This puts the responsibility squarely on the doctor’s shoulders. The codes change every year, so every year, as a doctor responsible for coding for your patients, seek out 2-3 hours of continuing education in the area of coding and billing.
One of our core beliefs is to complete all cycles of action while the patient is in front of you. If you code every patient while they are in front of you, while the case is fresh in your mind, your coding skills increase and coding becomes easier.
But what if the patient is not a third-party patient? Well, we have all had patients tell us they did not have third-party coverage when in the office only to get home and discover that indeed they do have third-party coverage. If the case is already coded by the doctor, staff can handle billing without requiring doctor time.
Another statement in the document is “The entire coding and medical industries are dependent upon accurate code use and interpretation to allow information to be accurately transferred between the provider and the payer.”
Just a couple of weeks ago a doctor was being audited, and based on the auditor’s comments, did not feel the audit was going well, so he called us with this question, “How closely must I follow code definitions?” The answer we gave is to follow the code definitions exactly. This means doctors need to know the code definitions in order to follow them exactly. If it’s been a while since you’ve read the definitions for the codes you routinely use, take this week to read them – and follow them exactly.
A helpful insight stated in this document is “Most carriers have published policies that follow the CPT closely, although it’s not uncommon to find that they may have specific policies or guidelines that build on the CPT definition for a particular code.” This is just complicated coding.
It’s not enough to know the CPT, ICD-10-CM, and HCPCS Level II codes, you must also know the carriers published policies and guidelines for the codes as well. That means there is more to read to make sure we are following the codes exactly. Most of this can be found on the carrier’s web site or in the carrier’s newsletters. For Medicare, the Federal Register also comes into play.
The document properly notes “… if it wasn’t documented, it never happened.” Medical necessity determines what testing is acceptable to a third party and documentation of testing determines what codes can be used. Accurate documentation is essential. It’s essential not only for third-party payment, but also for communicating to yourself and other doctors.
Heaven forbid that you would die today, but if you did, is your documentation clear enough that another doctor could step in tomorrow, understand your diagnostic and treatment logic in order to care for every patient you have seen so far this year? If not, take steps this week to improve your documentation.
The document states “It is strongly suggested that you utilize all resources available when you code for insurance filing.” There are many resources, including coding scrubbing software, that can be used, but they require us to take action to use them.
Take this week to review the resources you are using. Where are the holes? Where are you weak? What resources should you have? What steps will you take to improve your coding and billing? Don’t put this off.
