Hey, what would you code...?

Billing and Coding Update: Watch the video here.

This is a question I received on Thursday morning last week from a trusted colleague. I want to start off first by saying how much I respect his insights and the way he manages patients, he is truly an example of the type of person that makes our profession great! He is also an example of the challenges that face our profession in the sense that we often don't realize the value of the care we are providing. When clinical situations fall outside of our "normal" care, we too often can't figure out how to get reimbursed.

So the text I received was: "Hey what would you code if you brought back a glaucoma patient a week later only to recheck iop and review it in a minute or 2 in the room with them. No acuity or onh look taken. Just a really quick visit. 92100 serial tonometry?"

Again, I want to stress that this is the type of question I often receive, and many of us have had when we don't fully understand billing and coding.

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I will start by saying that the beauty of the CPT codes is that there is a specific code to describe (and be appropriately reimbursed for) every patient encounter. Unfortunately, if we don't understand the nuances of CPT codes and we get in to the routine of "just billing a 99213 or 92014" for most of our encounters, we not only are not reimbursed appropriately but we are at risk for audits (I will do a blog on this in the future). Further, it will create the uncertain situation my colleague found himself in. Serial tonometry is not the correct code for this situation, we will cover that in another post.

Fortunately, the 95 and 97 documentation guidelines allow us to understand the level of service that he provided to this patient. The coding is fairly straightforward for this encounter. Since this is an established patient we only need to score 2 of the 3 areas (I always recommend using Medical Decision Making as 1 area - it justifies medical necessity). We will score all 3 below just to illustrate the point.

After discussing the case with him further, he documented:

  1. Chief complaint (which isn't scored but establishes medical necessity) - Pt here for an evaluation of her IOP and glaucoma

  2. History (Problem Focused):

  • 1 Element of History of Present Illness (HPI) - Location: OU

  • No Past, Family, or Social history (PFSH)

  • No Review of Systems (ROS),

  1. Examination (Problem Focused) - 1 element (IOP)

  2. Medical Decision Making (Low)- 1 stable chronic problem (POAG)

Based on the documentation for this encounter, the appropriate code would be a 99212.

What is interesting about this chart audit is that he would have easily qualified for a 99213 had he done (and documented) a slit lamp examination and visual acuity (just 5 more examination elements), or documented 3 more elements of HPI and 1 ROS (ask about allergies to medications).

The bottom line is that there is an appropriate code for this (and every) encounter, and by using consistent principles of billing and coding we can determine the level of code that applies in each specific situation. Have a great week! - Chris