Article Date: 2/1/2009

Increase Profitability Through Accurate Billing and Coding

Increase Profitability Through Accurate Billing and Coding

Understand how to provide the standard of care for ocular allergy — and get paid for it.

By John Rumpakis, OD, MBA

When I ask optometrists, "What's your primary barrier to successfully performing medical eye care?" most of them say, "Coding." They're afraid their claims will be rejected or audited. How can you treat allergy therapeutically if you can't get paid for it?

In a private pay-fee-for-service world, things would be easier for us. But that's not how it works. And since the world of medical coding is so dynamic, we have to stay on top of the changes to effectively receive payment for the care we provide our patients. If you're comfortable with the value of care you provide your ocular allergy patients and with translating your professional services into the language of insurance carriers, then you can become confident about expanding your allergy practice.

This article will discuss the standard of care for ocular allergy, as well as accurate billing and coding strategies to ensure reimbursements.

What is the Standard of Care?

Typically, patients will find a way to get allergy relief even if they don't see a physician. Anecdotal data suggest that sales of over-the-counter eye drops for allergies are seven or eight times higher than prescription medications. As a businessperson, this tells me that optometrists aren't recommending robust solutions to patients, so patients are treating allergy on their own.

Our role needs to change. In fact, if we fail to address all of our patients' symptoms, we could be culpable for not providing the appropriate care for our patients. We can improve the way we treat allergy patients by defining the standard of care, which must include:

1. A thorough, complete medical record. For insurance purposes, this means taking notes that tell the whole story appropriately. As you know, the patient's chief complaint drives the encounter. If a patient needs help for ocular allergies, we must address that. However, many allergy-related visits are driven by the primary refractive or vision exam. You have to tell the story of how the exam, history or discussion with the patient leads to allergy treatment.

2. An appropriate, proactive recommendation. Every single code for an office visit stipulates that you must develop a diagnostic and/or treatment program. Your records should reflect how you're solving the patient's chief and ancillary complaints. Bear in mind that the best solution is the best solution — not the cheapest. You can't explain that you gave a patient something less than the best because you didn't think the patient could afford it. While it's good to give patients choices, it's important to provide them with recommendations. Always keep your patient's best interests in mind when recommending the most effective therapy.

Which Code System is Best?

In the United States, services and procedures provided by physicians are defined by the CPT, known as the Current Procedural Terminology (4th Edition). CPT-4 codes always include one 5-digit code for the initial procedure, and they can incorporate up to four 2-digit modifiers (for example, 92012-01-02-03-04).

In eye care, we have the choice to use the 920XX codes or the 992XX codes. One question I'm always asked is, "Which is the best code to use — a 992XX or a 920XX?" While you can use either for ocular allergy, both code subsets have their pros and cons.

The 992XX coding system is the only one used by other healthcare specialties. These codes generally require a higher level of documentation to meet the requirements that substantiate the level of service provided — and medical insurers always accept them. For these reasons, 992XX codes generally play a stronger role in medical eye care than 920XX codes.

Eyecare professionals are unique in that they have a second coding system — the 920XXs — to describe office visits. These codes require less documentation than 992XX codes, but their acceptance by medical insurers varies. For example, an insurer may only recognize the 920XXs for refractive visits. That varies from carrier to carrier, so you'll want to find out what is the common practice in your particular geographic area. But if you want to guarantee you'll get paid every time, use the 992XX codes. Using these consistently always will get you reimbursed with very little claim rejection for refractive services. Just remember that the documentation in the medical record must substantiate the level of service coded for that specific patient visit.

Service and Documentation Levels

If you code ocular allergy treatment with the 920XXs, visits fall under the intermediate exam codes — 92002 and 92012. Recently, I audited a doctor who was billing allergy with the comprehensive codes 92004 and 92014 because he received reimbursements at a higher level. However, this is generally inappropriate because there's not enough medical necessity established in the medical record to justify using a comprehensive visit code for ocular allergy patients.

If you use the 992XX codes for evaluation and management office visits, you have five different levels of service for new patients (99201-99205) and five for existing patients (99211-99215). Established patients have been seen at least 3 years by a physician within the same subspecialty. The vast majority of your ocular allergy visits would fall under either a level 2 or level 3 — 99202, 99203, 99212 or 99213, based on the patient's presentation. Several elements make up the evaluation and management rationale, including history, examination, medical decision-making, counseling, coordination of care, nature of the presenting problem and time. It's imperative that you consult with the 1995 or 1997 Evaluation & Management Guidelines1 published by the Centers for Medicare and Medicaid Services (CMS) for more information.

In determining the level of service, consider these three important areas: the level of history taken, the level of physical examination performed and the level of medical decision-making necessary to diagnose and treat the patient (Figure 1). Of course, you must document all of these elements accurately in the medical record.

Figure 1. When determining the level of service, consider the level of history taken, the level of the exam and the level of medical decision-making necessary to diagnose and treat the patient.

Keep in mind that if the primary examination you perform falls under the contractual obligation of a refractive plan, and you use a 920XX code to document the encounter, it's acceptable to bill the scheduled follow-up appointment to the medical carrier using the 9921X codes. While this may seem confusing at first, it becomes fairly straightforward over time, and you'll increase your confidence in properly coding office visits as you encounter real-world examples.

Sample Case

Consider a typical ocular allergy patient who presents with a chief complaint of blurred distance vision. You perform the appropriate level of 920XX services commensurate with his medical needs and determine that he's myopic. You prescribe refractive correction accordingly. However, during the slit lamp examination, you see signs of allergic conjunctivitis (both bulbar and tarsal), so you take an additional history and ask the patient if he has allergies. He says yes and tells you he's been using an over-the-counter medication. You record this in his chart and recommend a more effective treatment for his ocular allergies.

You might say something like, "I realize you're using an over-the-counter eye drop right now for your eyes, however, there's a much more effective medication you can use that has virtually no side effects. I'm going to prescribe Pataday (olopatadine 0.2%, Alcon Laboratories Inc.), which is my first medication of choice. It requires one drop a day. It will be easier to use and more effective." Next, ask the patient to return for a follow-up visit in a week or so. Some people say, "Allergy is easy to treat, and the prescription medications are safe, so why should patients come back?" If you write a prescription and never follow up, you won't know if the patient filled it and is using it correctly. The medical record should always mention the condition for which you prescribed the medication, whether it's being managed or has been resolved. You won't know this if you don't schedule a follow-up appointment.

Billing for the first visit includes a comprehensive examination and refraction. You'd bill the refractive carrier or the patient directly if he doesn't have insurance benefits. For the follow-up visit, you'd bill the patient's medical carrier or the patient if he doesn't have medical benefits or hasn't met his deductible. You could receive reimbursement for the initial follow-up visit for about $70 or so (using CMS maximum allowables as a guideline). You'd follow the standard of seeing the allergic conjunctivitis patient one more time during the year (in 6 months) or more based on the severity of symptoms. Many practitioners schedule follow-up visits to coincide with the refill frequency of the patient's medication.

Achieving Profitability

How could therapeutic treatment of ocular allergy affect your practice's profitability? To an extent, profitability depends on the amount of allergy treatment needed in your practice. One way to analyze this is to use the concept of chair cost. Chair cost is the breakeven point (no profit or loss) on an hourly basis for providing physician services only (no optical revenues or costs included). Using national statistics, the calculated national average for chair cost is $92 an hour; in other words, a physician needs to generate at least $92 an hour in service revenue alone just to break even.2 If we look at the economic profile for ocular allergy, based on the reimbursement rate averages and actual physician time required to care for the allergic conjunctivitis patient — profitability is averaging approximately $647 per hour (gross revenue minus chair costs). I'd consider this a fairly good hourly rate for managing something as straightforward as allergic conjunctivitis.

The economic potential is there. The current median income for optometrists is $140,000, derived from an average of 3,300 patient encounters a year.3 Based on recent data,4 I've calculated that ocular allergy affects about 42% of Americans, which gives us a potential allergic conjunctivitis population of about 1,370. If you followed the standard of care to see these patients for two follow-up medical visits a year outside of their usual eye exams, you could potentially add $185,000 in net income each year to your practice from allergic conjunctivitis alone. I realize it's highly unlikely to have a 100% capture rate, but even if you receive a 50% capture rate, you could potentially generate $90,000 a year. That's why I, like others, view medical eye care as an important component of optometric practice that often gets overlooked.

Realizing Your Potential

Allergy is easy to diagnose and treat with today's state-of-the-art medications. Optometrists have to work proactively to ensure patients understand that they're the best healthcare professionals to treat ocular allergies. Don't let anything hold you back from your potential. Integrate ocular allergy treatment, coding and reimbursement into your practice effectively. Your actions will have a positive impact on your patients, your practice and your own professional satisfaction.

To maximize your success, always practice in accordance with the standard of care, then translate your actions into CPT language. Make sure you communicate what you do to treat your patients. And always use the medication that offers the most relief and convenience, because the evolution of medical eye care depends on our ability to relieve ocular allergies fast and help patients maintain therapy over time. OM

  1. 1997 Documentation Guidelines for Evaluation and Management, Centers for Medicare & Medicaid Services. Visit Last accessed January 2009.
  2. Practice Resource Management, Inc. Calculated values from Caring for the Eyes of America, American Optometric Association, 2006.
  3. American Optometric Association, Caring for the Eyes of America, 2007.
  4. Practice Resource Management, 2008. Visit Last accessed December 2008.

Optometric Management, Issue: February 2009