Article Date: 5/1/2008

Hang on to What You've Earned
billing & coding

Hang on to What You've Earned

The second in a series of articles on how to keep insurance payments.


In pathology classes, professors display various unusual disorders on multimedia. If a student dares question the practicality of studying uncommon disorders, the professor advises, "it isn't rare if it's in your chair." As with the rare Fusarium keratitis outbreak, we should prepare for the infrequent audit because, "audits are few, unless they happen to you."


For audit and legal reasons, medical eye care involves documentation that is entirely different from routine vision-exam documentation. We have long used a 5-inch × 8-inch note card for documentation, especially for a healthy eye exam. Many of us have made a habit of using the note card, even after our privileges have expanded into medical eye care. On the other hand, physicians use the Subjective, Objective, Assessment, Plan (SOAP) format of medical care documentation.

Unfortunately, neither format is likely to meet the requirements of a medical-insurance audit — particularly in the case of Evaluation and Management (EM) office visits. This is because you have to record too many elements.

Imagine the financial consequences of failing an audit for all EM medical office visits due to lack of documentation. That day of reckoning has already come for some doctors.

Pre-printed solution

The simple solution to ensuring the proper documentation for EM medical office visits: Obtain pre-printed medical-office-visit recording forms. Be aware, however, that the transition from free-handing the data to EM documentation may take two to three months.

Obtain pre-printed medical-office-visit recording forms.

This means two months of decreased production. But take heart. After integrating EM documentation, it's common to be able to bill one or two levels higher for nearly every medical examination. Under-coding exams due to lack of documentation is widespread. EM documentation enables you to stop being under-paid for your services.

The second benefit: Medical-exam documentation is nearly "audit-proof." The exam recording form forces you to address every element of documentation. Consequently, determining the level of EM examination is a matter of adding the recorded elements. In other words, you define the level of examination by reviewing the elements, which is exactly what an auditor does.

The inherent danger in the use of a recording form: You may be tempted to make a mark next to every single element, just because you can. Pretty soon, every exam looks like an EM5. The level of an EM visit is limited by the complexity, risk and decision-making: Treating simple allergic conjunctivitis never rises to EM5 status, despite the completeness of history and examination.

Billing services

Many of you have turned to billing services to code and submit medical billings. While this is a convenient method of ensuring accuracy, be aware that you're ultimately responsible for the accuracy of the claim. Translation: Your records are audited, not the billing service's records. As a result, If you use a billing service, keep billing inhouse for better control.

Electronic health records

Sometimes viewed as the answer to a clinician's prayer, the electronic health record (EHR) is reputed to simplify if not automate the choice of EM level for billing.

Medical insurances and Medicare are evaluating the potential impact of EHR on medical billing. Of concern is EHR's ability to bring forward much of the prior examination, such that by the press of an electronic button, an exam could be made to look more comprehensive than it really is.

EHR may be as organized as a pre-printed, hand-recorded document, with the benefit of excellent readability. Therefore, it can assist you in retaining payment in the event of an audit.

EHR deadline: 2014?

Please take note: Currently no mandate or law exists for you to adopt EHR by 2014. This date was born out of President Bush's executive order, which mandates EHR availability to the American public by 2014. (See "Prepare to go Paperless," April 2008.) Many of you are concerned that the implication of this order is that Medicare won't reimburse you for your service if you don't submit a claim using EHR. Currently, however, no Medicare publication reveals that it has plans to make EHR mandatory.

Something else to consider: several sources suggest EHR won't likely ever obtain complete penetration in physician offices. According to an article published in The Wall Street Journal this February, "The Department of Health and Human Services is 'targeting 50% adoption by medical practitioners by 2014.'"

So, you may elect to invest in EHR. But, again, it's not yet a government requirement. OM


Optometric Management, Issue: May 2008