coding strategy

Just Give Me a Reason

“Surely your eyes are dry and itchy sometimes… Aren’t they?”

CHARLES B. BROWNLOW, O.D. , F.A.A.O

A few years ago, much of human behavior was credited to what were called Murphy’s Laws: “If anything can go wrong, it will,” “Nothing is as easy as it looks,” etc. As someone who has helped doctors and staff understand medical record keeping for 20 years, I would add, “If anything can be made more complicated and difficult to understand, it will be.”

The plan perplexity

I’ve listened to colleagues discuss the challenges of knowing whether the claim for a patient’s care should be sent to his/her vision plan or medical plan and have heard these replies: “Bill it to whichever plan has the higher reimbursement.” “That’s easy. If the patient has a medical plan, just keep asking questions until he/she admits experiencing dry eyes sometimes, or a headache.” And, “Whatever you do, don’t make the patient angry. Irrespective of their real reason for the visit, send the claim to the plan that has the lower copays and deductible.” The insurer may even say it’s the patient’s call. This is getting ridiculous-er and ridiculous-er.

Simplifying plan selection

Medicare made the decision regarding plan selection simple several years ago through its policy in its manual. Essentially, the policy states that reimbursement for covered services is based on the reason for the services and not upon any diagnoses resulting from the services. The manual states that, if the reason for the visit is medical, the services are reimbursable even if no medical diagnosis is discovered during the visit. And, even more important, if the reason for the visit is not medical, the visit and its appurtenant services are not reimbursable even if one or more medical diagnoses are discovered during the visit. It’s the reason for the visit, or the reason for providing the services, that drives the bus, not the diagnoses discovered during the visit or as a result of tests.

Going back to basics

The very first line on the medical record, paper or EHR right below the patient demographic information is the reason for the visit. Even though it is often mischaracterized as the “chief complaint” (“CC”), doctors and staff should be concentrating on finding the “reason” the patient has presented. The reason may be obvious at the beginning of the visit — “Patient RTC at Dr.’s request for recheck of POAG and repeat of visual fields” — or it may be unearthed later, even during the physical examination or case presentation, when the patient finally gets the courage to disclose why he/she presented.

Early or late, it is the primary responsibility of you, the doctor, to identify the reason the patient came to see you. Once the reason is identified, the elements of the case history and examination are customized to match that patient’s needs on that day. Indeed, each visit is unique, based on the needs of the patient, as identified by you, and the record for the visit should reflect that uniqueness.

It’s not perplexing

Higher reimbursement? Happier patients? “Simpler” insurance company rules? I’m confident all these issues will take care of themselves if doctors go back to the basics and base all care upon the unique needs of the patient during each visit. OM

DR. BROWNLOW HAS 20 YEARS EXPERIENCE IN PRIVATE EYECARE PRACTICE, WORKING WITH O.D.S AND M.D.S AND HAS BEEN A CONSULTANT TO EYE DOCTORS SINCE 1994. HE NOW PROVIDES BILLING AND CODING CONSULTING SERVICES THROUGH PMI, LLC. E-MAIL HIM AT BROWNLOWOD@AOL.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.