BUSINESS
coding strategy
All is Well That Ends Well
Two requirements for billing preventive care
JOHN RUMPAKIS, O.D., M.B.A.
The concept of wellness care — preventing illness and prolonging life as opposed to treating diseases — is gaining greater visibility throughout the healthcare system.
In eye care, wellness is discussed in many areas: refractive issues (accommodative and binocular disorders), preservation, enhancement, and management of the ocular surface (reducing dry eye, meibomian gland disease, contact lens dropouts) and retinal care (diabetes and AMD).
As a concept, wellness resonates with the healthcare consumer, and prevention of just about everything is discussed in social media and other channels. This popularity drives business decisions in the optometric practice as well. O.D.s seek out technologies that allow them to capitalize on this trend and provide wellness care to their patients, helping their financial bottom line.
However, the temptation sometimes arises to bill a medical insurance carrier to avoid the patient having to bear the cost for these services; and therein lies the risk.
Necessary requirements
In order for a medical carrier to ever be involved in paying for patient care, two requirements must be fulfilled and recorded in the medical record: 1) the chief complaint and 2) medical necessity.
1 The chief complaint. Let’s revisit the definition of the chief compliant from the Medicare Carriers Manual and see why wellness care may pose a problem: “The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition.”
Clearly, if we are approaching wellness from the prevention side of things, there could be difficulty in meeting the requirement of the patient presenting with a complaint or symptoms of an eye disease or injury. And then, by definition, a traditional medical carrier would not participate in reimbursement.
2 Medical necessity. With respect to medical necessity, it is imperative to understand that any office visit, special ophthalmic procedure, surgical procedure or other clinical test must be noted in the medical record as being necessary to (a) diagnose a condition; (b) follow an established diagnosis of a condition; (c) treat a condition; or (d) follow the treatment of a patient’s condition. If the necessity for doing something with the patient isn’t recorded properly, then the clinician faces risks should those services be paid for by a medical carrier.
Navigating wellness care
Wellness is a concept that is growing within the population and is becoming a larger part of the ophthalmic landscape as well. Don’t let the lack or challenges of insurance coverage or payment stand in your way of offering those services. The key is knowing when it is applicable and appropriate to have the medical carrier participate and allow the patient to take advantage of their contracted benefits. OM
DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.