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Coding and Billing: Advanced Diagnostics

Before you put that shiny, high-tech instrument into practice, keep in mind the golden rules of responsible coding and billing.
By John Rumpakis, O.D., M.B.A.

8/22/2011

You just bought a brand new, high-tech diagnostic instrument. You know that feeling—it’s just like getting a new car. It’s shiny and modern. It has all sorts of buttons to press and gizmos to learn. And you just can’t wait to start using it. As with many new things, we begin to use it before we even read all the instructions that came with it. Snapping images here, measuring thicknesses there. Wait, need that pressure taken? Be right there with my new gadget.

The technological advancements available today to the practitioner in clinical practice boggle the mind. And yet, while these advancements allow the average practitioner to deliver higher levels of care, they also come with some pitfalls—not necessarily from the clinical side of things, but from the medical coding and compliance area.

And that’s where things get interesting.

Profits and Patients
Sales representatives are amazing sources of information. They are knowledgeable and well trained in their specific technology. But, in nearly all cases, medical coding experts they are not… Maybe the best way to put it is that they just don’t know what they don’t know. After all, their job is to sell the equipment, not to protect you from an audit.

How often have you heard a sales rep say something like, “Doctor, our monthly payment is only $X,XXX and you will only need to do XX procedures to make your monthly payment.” An economic analysis almost always accompanies the clinical data. (In fact, as a consultant, I myself have provided many companies with that economic analysis.) So, decisions to purchase equipment are, in many instances, not based on patient care but based upon projected profitability.

Of course, economics are not a bad thing. (Heaven knows, I’ve been a prophet for nearly three decades for higher profitability within our profession.) But profitability at the expense of creating a dangerous liability in your medical records or exposing you to an audit is not the right thing to do.

Know What You're Doing Before You Do It
Back to the shiny, new, button-festooned, gizmo-loaded new instrument… It’s just been unpacked, the tech team has scheduled the training session, and you’ve closed down your office just so you can learn how to do the “procedures.”

Now somewhere in between “this is how you turn it on” and “this is a list of covered diagnoses we’ve put together for you” lies responsibility. As the practitioner, you are responsible for understanding medical coding and compliance basics. This includes concepts such as indications and limitations of medical necessity, utilization patterns, recording requirements, chief complaint, and interpretation and report.

So, as with anything, the best antidote to fear is knowledge. The following fundamental guidelines apply to all technology that you employ in your practice.

Medical Necessity
Medicare defines medical necessity as: “Services or supplies that are proper and needed for the diagnosis or treatment of the patient’s medical conditions, are provided for the diagnosis, direct care and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or the physician.”1

However, carriers may also have their own version of medical necessity. So if you’re a contracted provider, you must be not only familiar with but uphold that specific carrier’s definition with their beneficiaries. (See “More on ‘Medical Necessity’ and ‘Medically Necessary.”)

Keep in mind that you must demonstrate in the medical record that the procedure or test is needed in order for you to diagnose, treat or monitor treatment of the patient’s condition. Think of the medical record as a storybook—it has a beginning, a middle, and an end. As the physician, you must tell the story of the patient’s encounter, including your reasoning, or thought process, for what you are doing. If you feel that a procedure is needed or necessary to aid you in the diagnosis or treatment, then tell the record why you feel that way. It’s your only defense in a post-payment review process.

More on ‘Medical Necessity’ and ‘Medically Necessary’

In addition to Medicare’s definition of Medical Necessity, you’ll also need to be familiar with the definition provided by any carriers for which you’re a contracted provider. 

As an example, here is CIGNA HealthCare’s “Definition of Medical Necessity for Physicians.”2

“Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

a) In accordance with the generally accepted standards of medical practice;
b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c) Not primarily for the convenience of the patient or physician, or other physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community; physician specialty society recommendations; the views of physicians practicing in the relevant clinical area; and any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable plan documents.

(CIGNA HealthCare also has a similar definition intended for “other Healthcare Providers.”)

To sum it up: Tell the record not only what you’re going to do with the patient, but tell the record why you’re doing it.

If you follow this principle, you’ll have a much better chance of defending your reasoning at some point in the future (when your memory isn’t as good as it should be). This makes you go through the process of defending the order in writing prior to actually performing it. Remember, ignorance is not a valid defense.

Chief Complaint
The chief complaint is another one of the “holy grail” coding rules to follow. The Centers for Medicare & Medicaid Services (CMS) says: “The coverage of services rendered by a [physician] is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to a [physician] with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered, even though as a result of such examination the doctor discovered a pathologic condition.”3

Simply put, the chief complaint is the very foundation for determining whether an office visit or procedure can be billed to a medical carrier. Also, it dictates whether you can do any additional testing.

Keep this in mind as you’re teaching or instructing your technicians in the art of taking a case history. Take heed in not misrepresenting or manufacturing a reason for the patient to have additional tests performed in your office.

Covered Procedures
Temptation abounds when you have a high-tech practice. There are a whole host of patient symptoms that appear in lists of “covered diagnoses” for a specific procedure. For example, subjective visual disturbance–unspecified (ICD-9 368.10) would return threshold visual fields (CPT 92083) as a covered procedure.

However, the ICD-9 is very specific in what we can—and can’t—use as a billable diagnosis. The ICD-9 states: “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.”4 In other words, practitioners cannot do any test they want because the symptom is covered; they must base their decision on the actual diagnosis.

So, in the example above, if the practitioner determined that the cause of the subjective visual disturbance or blurred vision is a cataract, then cataract is the appropriate diagnostic code to use. If visual field testing was not a covered procedure for cataract, then the practitioner cannot bill the carrier for the procedure.

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.

Interpretation and Report
The average optometrist is getting more involved in high-tech diagnosing through the use of advanced instrumentation. Among the most common clinical technologies owned by optometrists, as many as nine out of 10 practices (91.8%) have an automated perimeter. Four out of five (80.8%) have an autorefractor/autokeratometer. And at least three out of four (75.2%) have a pachymeter, according to the AOA’s New Technology Survey, based on 2009 data.5 (See “O.D.s Utilizing Technologies in Clinical Practice, 2003-2009.”)

The technologies popping up most rapidly in O.D. offices in the past few years have been scanning laser ophthalmoscopes and pachymeters.5 (For comparison, see Review’s own 2011 Diagnostic Technology Survey, “2011 Technology Trends: Patient Care Reigns Supreme.”)

This trend of using advanced instrumentation will certainly continue its upward trajectory. As technology continues to advance and costs decline, these instruments will be more accessible to the average practitioner.


Among the most common clinical technologies owned by optometrists, as many as nine out of 10 practices (91.8%) have an automated perimeter. Four out of five (80.8%) have an autorefractor/autokeratometer. And at least three out of four (75.2%) have a pachymeter, according to the AOA’s New Technology Survey, based on 2009 data.5

Today, most any advanced diagnostic testing performed requires an interpretation and report, and should have the following items documented in the medical record to fulfill this requirement:

• An order for the test.
• The patient’s name and date of the test.

• Indications for the test.
• An interpretation of the results with a report.
• Diagnostic or treatment plan based upon results.
• Your signature.

Despite what you may have heard, there is no specific form required for the Interpretation and Report; it can simply be incorporated into the medical record. However, it is imperative that the medical record shows that the interpretation and report is very clearly tied to the specific test performed, and that an objective third party (e.g., an auditor) can follow the test and your interpretation of it.

When Services Aren't Covered

Simple Steps to Bill Advanced Technology Safely

    • Make sure the patient has a condition that requires a special test that would provide necessary information for you to diagnose a condition, treat or follow a condition, or monitor ongoing treatment.
     • Make sure that the diagnosis used on the CMS-1500 form is for the condition diagnosed and not for signs and symptoms, unless you have not reached a definitive diagnosis. Always be sure to code to the highest level of specificity for the diagnosis in accordance with ICD-9-CM rules.
     • Link the CPT code for the special ophthalmic test to the appropriate diagnosis on the CMS-1500 form. Be sure you know the definition of the test ordered. For instance, is it a “unilateral” or “bilateral” test, or is it “unilateral or bilateral”? This will affect your billing units and total charges.

     • If billing a third-party carrier, be sure to have a covered diagnosis that is appropriate for the situation. Use online resources, such as www.LCDPlus.com, for zip code-specific CPT codes or refer to the CMS website for your specific carrier information. (Disclosure: LCDPlus.com is my company.)
     • Be aware of any Correct Coding Initiative (CCI) edits that would prevent you from performing a specific combination of tests on the same day of service. Online resources, such as www.CCIPlus.com, can provide you with up-to-date data to avoid CPT code bundling conflicts. (Disclosure: CCIPlus.com is my company.) You can also look up the CCI edits, as well specific CPT code combinations, on the CMS website.
     • Make sure that your medical record is pristine, and clearly outlines the order for the test, the reasoning behind ordering the test, your interpretation of the test results, and your game plan for continuing your diagnostic and/or treatment protocol.
 
Changes in health insurance abound, but one thing remains constant: Carriers don’t or won’t always pay for a test that you may feel is necessary, even though you have met all of the above-mentioned criteria. There are proper rules and processes that you must go through to provide appropriate notification to patients so they can make educated decisions regarding their own care, and allow you to legally collect from the patient rather than the third-party carrier. The most common method to provide such notification is the Advanced Beneficiary Notice (ABN). Published by CMS, the ABN is a widely accepted form for allowing the appropriate and legal notification process and transfer of financial liability from the carrier to the patient.6

When using an ABN, be sure to follow the rules and guidelines published by CMS because the forms and rules change very frequently. The most current version (available at www.cms.gov/BNI/02_ABN.asp) is dated June 20, 2011 and has a mandatory use date of November 1, 2011.

Also, you must use specific modifiers to indicate to the carrier that you have an ABN on file:7

-GA Waiver of Liability Statement Issued as Required by Payer Policy. This modifier is used to report that a required ABN was issued for a service and is on file. A copy of the ABN does not have to be submitted but must be made available upon request.
-GX Notice of Liability Issued, Voluntary Under Payer Policy. This is used to report that a voluntary ABN was issued for a service.
-GY Notice of Liability Not Issued, Not Required Under Payer Policy. This is used to report that an ABN was not issued because the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
-GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary. This is used to report that an ABN was not issued for a service.

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. Embrace new technology as it allows us to provide better and more thorough care for our patients, but keep in mind that as new technology evolves, so will our challenges in properly coding for it.

I’ve attended many lectures and have read many publications that tout the economic advantages of incorporating advanced technology into practice. While the economic benefits are certainly achievable, reimbursement and profit shouldn’t be your primary motivation.

Remember that increased profits are only a byproduct of providing the standard of care, fulfilling the rules of medical necessity, proper and appropriate medical record keeping, and accurately coding from only what is in the medical record. Done in this order, you will have benefited the patient, protected yourself, and perhaps also put a little more green into your practice’s bottom line.

Dr. Rumpakis is the founder of Practice Resource Management, a management and consulting firm. He lectures nationally and internationally on practice management topics, as well as on managed care, contact lenses and refractive surgical procedures. He is Clinical Coding Editor for Review’s “Coding Abstract” column.

1. Glossary. Medicare. Available at: www.medicare.gov/glossary/m.html. Accessed June 21, 2011.
2. Medical Necessity Definitions. Cigna HealthCare. Available at: www.cigna.com/health/provider/medical/procedural/medical_necessity.html. Accessed June 21, 2011.
3. Medicare Carriers Manual, Part 3 §2320. Available at: www.cms.gov/manuals/downloads/P14_03.zip. Accessed June 21, 2011.
4. Buck CJ. ICD-9-CM 2011 for Physicians: Professional Edition. Chicago: American Medical Association; 2011: 11.
5. AOA technology survey shows pachymetry, SLO now common in OD practices. AOA News. 2009 Sept 1;3(48):1,6. Available at: www.aoa.org/documents/AOANews/September-1-2009.pdf. Accessed June 21, 2011.
6. FFS Revised ABN. Beneficiary Notices Initiative (BNI). Centers for Medicare & Medicaid Services. Available at: www.cms.gov/BNI/02_ABN.asp. Accessed June 21, 2011.
7. Advance Beneficiary Notice of Noncoverage (ABN), Part A and Part B. 2nd ed. Centers for Medicare & Medicaid Services. April 2011. Available at: www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf. Accessed June 21, 2011.



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