By Charles B. Brownlow, OD
When I did my first presentation on medical record keeping after the release of the 1997 Documentation Guidelines for the Evaluation and Management Services (99000 codes), I was sure that the document would finally spur doctors and insurers to learn and follow the rules. The ‘DGs’, as we refer to them, provide a very simple explanation of the logic of the delivery of health care services, followed by a very objective, detailed set of instructions for creating good medical records and for choosing 99000 codes accurately.
The word ‘objective’ in the previous sentence means that doctors and staff could choose codes exactly as insurers are required to choose them. Doctors adhering to the definitions for services provided by the Current Procedural Terminology (CPT © American Medical Association) and the DGs would never have to worry about an audit by Medicare or any other insurer. All a doctor would need to do for visits would be to provide the care the patient needs; no more, no less; keep an excellent record of all that happened during the visit, and then choose a code to represent the content of the record.
For the first time in history, the process of choosing visit codes can be accurate, objective, and repeatable, with those three characteristics ensuring appropriate reimbursement for services provided and ‘no hassle’ chart reviews or audits. When I first read the DGs in July of 1997, I was ecstatic! Our colleagues would no longer have to worry about choosing codes nor about being audited. I was doubly ecstatic because the 1997 DGs were the first guidelines to provide guidelines customized for eye specialists.
The original guidelines required doctors to examine at least nine organs systems, actually doing at least two tests on each system for the physical examination portion of a visit to qualify as ‘comprehensive’. With the 1997 DGs, eye doctors could reach the previously acrophobic level of comprehensive physical examination (and thus the higher level codes that require comprehensive physical examinations) simply by doing twelve ophthalmic elements and two psychiatric elements (mood and affect and orientation to time, place and person.)
Furthermore, the required ophthalmic elements have traditionally been included in a typical eye examination; acuities, gross fields, examination of the adnexa, pupils and irises, motility and versions, corneas, anterior chambers, crystalline lenses, bulbar and palpebral conjunctiva, IOPs, and dilated ophthalmoscopy (discs and peripheral retina). Wow! The 1997 DGs made it possible for eye doctors to appropriately choose the higher level 99000 codes; 99215, the 99204 and even the 99205 (albeit rarely); for the first time since CPT created the 99000 codes in 1992!
Being the eternal optimist that I am (or that I was in 1997), I assumed the 1997 DGs would be immediately embraced by ODs and OMDs, who would quickly learn of their simplicity and accuracy and objectiveness and repeatability, and would begin using them immediately. Obviously, I could not have been more wrong. Here we are, eighteen years after the introduction of the 1997 DGs, and the typical OD and OMD still don’t understand the power that the document provides them.
As a matter of fact, based on my experience with the hundreds of audiences I’ve faced during those years, I’m pretty confident in estimating that fewer than 30% of all eye doctors have ever read the 1997 DGs, even though a relatively high percentage of eye doctors use them in their practices every day! Talk about self-destructive behavior. Without understanding the DGs, it doesn’t matter whether the doctor, the doctor’s staff, or the doctor’s EHR software is choosing the codes, the audit will be ugly. Even worse, without knowledge of the DGs, the doctor and staff will be helpless in attempting to defend themselves in an audit…Even though the auditor probably doesn’t know the DGs well, either.
As long as we’re getting depressed, let’s consider another ‘elephant in the room’, probably larger than the DG issues. Thousands of eye doctors in the US are reporting their visits to insurers using the comprehensive ophthalmological services (CPT©AMA codes 92004/92014), without knowing the definition for those services. Let’s do a little math. If we assume that 40,000 eye doctors in the US are each using these codes 2,000 times per year, that would represent 80 million uses of that code per year. If we generously assume 50% of those doctors actually have read the CPT definition, understand it, and appropriately apply it, that could mean up to 40 million potential incorrect choices of the code every year. Imagine the potential impact on these two professions that a sweeping audit of those two codes would produce. 40 million incorrect claims, even at $100/claim would be $4 billion!
Will thoughts such as these get the attention of America’s eye doctors and staff? Will thoughts such as these get the attention of American insurers? Sadly, I’d bet on the latter before the former, though it is clearly the former; America’s eye doctors; that I have devoted my professional life to.
What can be done about this? What can the AOA and AAOphthalmology do? What should the educational programs for tomorrow’s doctors of optometry and ophthalmologists do to correct these issues? I believe it starts where it should have started back in 1997; with the practicing doctors. It starts with downloading a FREE copy of the 1997 Documentation Guidelines for the Evaluation and Management Services from the CMS website; https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf It starts with buying the 2015 American Medical Association Current Procedural Terminology from AMA ($114.95) amastore.com, 800-621-8335) or at a member discount (approximately $100) through the American Optometric Association (aoa.org/marketplace, 800-991-4100). AMA is the only CPT that is the national standard for procedural coding, so don’t mess with substitutes…They cost more and you cannot defend yourself in an audit without the official AMA CPT.
In short, no more excuses. Just reading the first few pages of the AMA CPT and the 1997 DGs will help docs and staff understand the key links between excellent patient care and excellent records. In my opinion those two documents should be ‘required equipment’ for all eye doctors and all future eye doctors. CPT is only good for twelve months, so new copies must be ordered each December for the coming year. I know, I know, $100/year seems like a lot of money to some, but measured against the huge, looming expense of ugly audits, it’s ‘peanuts’! Let’s face it, CPT and the DGs; though they’ve largely been ignored by health care providers for decades; are priceless.
Please don’t put it off another 18 years. Act today!
This chart represents the variability in total costs across an episode and how the OHT envisions introducing risk and gain sharing. While the initial episodes chosen do not directly involve optometric care, we are confident that as the list grows to the expected 50 episodes they will likely include diabetes, glaucoma and/or cataract care. The OOA has been engaged with the OHT so will be part of the stakeholder groups helping to shape this effort.
