BUSINESS

  CODING STRATEGY

MAXIMIZE YOUR MEDICAL SERVICE

FOLLOW THESE THREE BASIC PRINCIPLES FOR SUCCESSFUL CODING

JOHN RUMPAKIS, O.D., M.B.A.

I HAVE long been an advocate of building the professional services of an optometric practice, in parallel to its retail services. The term “medical model,” as it is referred to, is limiting. Why not call it the “total eye care model?”

Optometrists provide the vast majority of first-time eye care visits in the U.S. in addition to ongoing care. Additionally, increases to the scope of license allows us to provide more medical services. Therefore, the opportunity to maximize our medical services exists. But, we also have to know the rules surrounding the description of the services that we provide (coding) to keep ourselves out of harm’s way. Increasing income by providing medical eye care is simply a by-product of providing the standard of care to your patients and coding correctly from what is written into your medical record. One should never be putting patient economics above patient care.

BASIC PRINCIPLES

First, always establish the medical necessity for any level of office visit, test or procedure in the medical record. For medical carriers, do not assume that a comprehensive exam is the appropriate level of service to provide. You must provide the level of service that is commensurate with the patients’ problems. CMS has clearly spelled out its view on medical necessity of office visits. This also applies to any special ophthalmic procedure. You can neither perform tests just to establish a baseline on a normal patient, nor perform tests without a documented reason why they are necessary to the outcome of the patient’s condition. ICD rules also prevent you from using the patient’s symptoms as a diagnosis to drive testing, particularly when you know what the diagnosis is. You must determine that each test your order and perform is necessary and will contribute to the outcome of the patient.

Second, remember the chief complaint is what drives the encounter and who the responsible party is for billing and payment. Just because a patient has hypertension or lupus doesn’t mean that you can bill the medical carrier for the encounter, particularly if the reason the patient is in your office is for his or her annual managed vision care examination.

Third, remember the golden rule: One fee per CPT code no matter who is paying the bill. You must charge all parties the same fee for the same procedure. If you are willing to bill a medical carrier for hundreds of dollars in ancillary tests/procedures you must also be willing to bill the patient individually for the same amount, particularly in today’s world where the patient’s deductible may be so high that he or she will be paying for the care out of pocket until the deductible is satisfied.

BOTTOM LINE

Maximizing the medical side of your practice doesn’t need to be risky if you: provide the local standard of care the patient’s clinical condition requires; follow the rules in your geographic location, and be compliant with the contractual requirements and policies of contracted carriers. Medical eye care and proper coding will certainly add to your bottom line, but make sure that you are in compliance and doing it for the right reasons. Your patients deserve that. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.