BUSINESS: coding strategy
Temper Your Tech Temptations
Overusing your new device can expose you to an audit.
JOHN RUMPAKIS, O.D., M.B.A.
While technological advancements allow the average practitioner to deliver higher levels of care, they also come with some pitfalls. Despite being a clinical benefit, new technology can be a medical coding and compliance challenge.
I want it!
Decisions to purchase equipment are often based on projected profitability. Conversations with sales representatives might be, “Doctor, your monthly payment is only $X,XXX, and you will only need to do X procedures to make your monthly payment.”
An economic analysis almost always accompanies the clinical data. Economics aren’t a bad thing — I’ve been an evangelist for higher profitability within our profession for 30 years, but not at the expense of creating a dangerous liability in your medical records or exposing you to an audit.
It is easy to succumb to temptation to overtest when you have a high-tech practice. You just purchased the button-laden, gizmo-loaded new instrument, scheduled the training session and closed your office down just so you can learn the “procedures.” Somewhere between “this is how you turn it on” and “this is a list of covered diagnoses” lies the responsibility of establishing medical necessity for ordering these tests or performing these procedures.
You must demonstrate in the medical record that the procedure or test is needed for you to diagnose, follow a diagnosis, treat or monitor treatment of the patient’s condition.
As the physician, you must tell the story of the patient’s encounter, including your reasoning for what you are doing. If you feel that a procedure is necessary to aid you in the diagnosis or treatment, tell the record why you feel that way. It’s your only defense in the post-payment review process.
A host of patient symptoms appear in lists of “covered diagnoses” for a specific procedure. However, the ICD-9 (as well as the delayed ICD-10) is very specific in what we can and can’t use as a billable diagnosis.
Current ICD-9 rules indicate that codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes only when a related definitive diagnosis has not been established (confirmed) by the provider.
In other words, you cannot test just because you have a covered diagnosis; you must base your decision to order the test solely on medical necessity.
To be compliant, practitioners must keep the ICD-9 rules in mind when ordering special tests based upon the actual diagnosis, not the symptoms. Remember that HIPAA requires us to follow the rules of the ICD-9, so we are legally bound to do so.
Remember the rules
New technology means new methods of delivering better care to our patients and the ability to diagnose disease at much earlier stages. But, new technology also means new rules and regulations.
As technology evolves, so will our challenges in properly coding for it. OM
Optometric Management, Volume: 49 , Issue: May 2014, page(s): 70