Article Date: 3/1/2010

BREAKING The Code
billing and coding

BREAKING The Code

Becoming an expert in just one code can simplify this process across the board.

MILE BRUJIC, O.D., Bowling Green, Ohio

► BILLING AND CODING ISSUES continue to be a challenge in many optometric practices. Although the concept is simple — specific codes identify the diagnosis established and the procedures performed — coding has become increasingly complex, particularly as our practices expand to include medical eye care.

I am a partner in a multi-location, multi-doctor optometric practice. My partners and I sometimes question one another on why we selected certain levels of office visits. After a few of these conversations, I realized I could not comfortably answer these questions. I often selected the level of the office visit I felt was representative of the services I provided, but I couldn't describe the specific reasons why. It concerned me that if I was ever audited, I would not be able to justify my office visit level selection based on current procedural terminology (CPT) guidelines. I knew I needed to know more about coding.

When I analyzed my patient encounters, I realized I was severely under-coding my level of service. I was using established level 2 codes (99212) most often, while the most commonly coded visits in eye care for established patients are level 3 (99213) office visits.1 I had to ask myself: Why was there such a discrepancy between how I was coding my visits compared with national averages, and was I, in fact, accurately translating my office visits into the codes I used?

Figure 1. This diagram shows a simple way to analyze patient encounters to determine the appropriate level of the office visit.

During this period of introspection and analysis, I developed a simple method to ensure I was coding appropriately. I will share that method with you in this article. First, it's important to understand the basis for these codes.

Components and elements

For the purposes of this discussion, I will discuss how to code established office visits. There are five levels of established office visit codes: 99211, 99212, 99213, 99214 and 99215. The last number in the code represents the complexity of the encounter from 1 (least complex) to 5 (most complex). The requirements for these codes are well defined in the CPT guidelines. For every encounter we need to consider three factors: history, examination and medical decision-making.

The history has three components:

► History of present illness (HPI). This is the reason the patient came in to see you; it has eight elements.
► Review of systems (ROS). This is the patient's current health status; it has 14 elements.
► Past, family and social history (PFSH). This describes family history and social habits; it has three elements.

The components of the history and the elements of each component are summarized in Table 1.

The examination has 14 elements, which are summarized in Table 2. Note that visual acuity should be measured at every visit, and posterior segment assessment must be done through a dilated pupil (unless contraindicated) to be included as an element of the examination. Also, keep in mind that mood and affect (i.e, depression, anxiety, agitation) and orientation to time, place and person are two separate identifiable elements that will likely be assessed at every visit.

Medical decision-making complexity is based on: 1) the number of possible diagnoses and/or the number of management options that must be considered; 2) the amount and/or complexity of the medical records; and 3) the risk of significant complications, morbidity and/or mortality, as well as comorbidities associated with the patient's presenting problems.

Every level of office visit has certain criteria that must be met in the patient encounter. Our daily challenge is to quickly and accurately determine the level of history, examination and medical decision-making complexity we perform for every patient encounter to accurately translate services performed to proper CPT code.

Breaking it down

Because the 99213 code is the most commonly used office visit code in eye care,1 we can set this as our standard and become an expert on the criteria required to achieve this level of service.

For the history to qualify as a 99213, we must record one to three components of the HPI and at least one component of the ROS (known as an expanded problem-focused history). No information about the PFSH is required to qualify the history for a 99213 visit.

For the examination component of the office visit to qualify as a 99213, we must have performed six to eight of its 14 components (known as expanded problem-focused examination). Remember that we must address only two of the three components of the office visit for an established patient to be able to use the 99213 code. So if the history and examination portions of the office visit meet the 99213 requirements, regardless of the level of medical decision-making complexity, the encounter is appropriately recorded as a 99213, as summarized below:

1) History

a) HPI – 1 to 3 components
b) ROS – 1 component
c) PFSH – none required
2) Examination – 6 to 8 components
3) Medical decision-making – inconsequential if previous two are met. In my experience, the level of medical decision-making complexity is usually the level met by the previous two components of the encounter.

Reviewing the encounter

After I see an established patient and have finished my notes, I review the HPI to determine if it contains one to three elements and if one element of ROS was addressed. Then I review the examination to determine if six to eight of the 14 elements have been examined. If the history and examination components have been fulfilled as described, I code the office visit as a 99213.

I have become extremely efficient at identifying the 99213 visit, which serves as a benchmark from which I can easily determine if a visit should be coded at a higher or lower level. If the office visit notes are not consistent with a 99213, then I determine if each component of the visit has more or fewer requirements fulfilled than needed for 99213. A 99212 visit, for example, has the same HPI requirement (one to three elements) as a 99213, but it requires no ROS and PFSH elements, and one to five elements of the examination. For an established office visit, you need to meet the criteria for two of the three components.

For a 99214, the history portion requires the following criteria for each component:

► HPI — at least four elements
► ROS — at least two elements
► PFSH — at least one element.

An easy way to remember this is that the 99214 visit requires one more element for each component than is required for a 99213 office visit. The same formula applies for the examination component. For a 99213 office visit, six to eight elements are required for the exam component; for a 99214 visit, nine elements are required.

Both 99211 and 99215 account for less then 2% of total office visits in eye care for established patients. This is representative of what I see in our office. If I think an office visit qualified for either of these codes, I consult my CPT guide to determine if, in fact, it meets the requirements.

I use the same logic with office visit codes for new patients. I am extremely efficient at identifying a 99203 (which is a level 3 office visit for a new patient). I use the strategy outlined here to identify other levels of office visits for new patients.

Code with confidence

This article is not intended as a comprehensive overview of coding office visits, but rather as a guide to simplify selection of office visit levels for the practicing clinician. Since adopting this system, I have discovered that approximately 90% of the visits I previously coded as 99212 were actually 99213. So in addition to being able to confidently code the level of service I provide, I have increased reimbursement to the practice. Becoming an expert in the most commonly coded visits will allow you to complete this most necessary task and ensure that your practice is reimbursed appropriately. OM

1. http://www.ophmanagement.com/article.aspx?article=86705

Dr. Brujic is a partner in a 4-location optometry practice in Northwest Ohio. He practices full-scope optometry with a special interest in glaucoma, contact lenses and ocular disease management of the anterior segment. E-mail him at brujic@prodigy.net


Optometric Management, Issue: March 2010