Blogs or Books? Guesses or Guidelines? It’s time to get serious about good medical records.

By: Charles B. Brownlow, OD  (drbrownlow@pmi-eyes.com)

Several years ago, I found myself jumping from one eye care chat room to another, trying in vain to correct bad information about patient care and record keeping that kept popping up there.  It seemed that my colleagues in eye care would rather ‘take a poll’ of other ODs and staff (who didn’t know the answer either) rather than go to the only true authorities.  After getting totally frustrated in that ‘Whack a Mole’ environment, I respectfully and quietly withdrew from the milieu, and I haven’t missed it one bit.

Over a decade ago, during the ramp up to HIPAA, the rules changed essentially clarifying that Current Procedural Terminology (©American Medical Association), ICD-9, and the Documentation Guidelines for the Evaluation and Management Services (99000 visit codes) were the sole acceptable references for codes and definitions for the vast majority of health care services.  That thought clarifies nearly everything in health care…All a health care provider needs to do to learn about the logic of health care delivery, good medical record keeping, and accurate choices of procedure, visit and diagnosis codes is purchase the current year’s CPT and a fresh ICD manual and download the 1997 Documentation Guidelines from CMS.gov.

Based on the questions that I get every day from ODs and staff from around the country, it’s pretty clear that a majority of those offices do not have those key references available in-house, or they are not current, or they just don’t refer to them when question arise.  That’s pretty sad, I think.  CPT is available through our AOA.org/marketplace at $100 a copy.  The Documentation Guidelines are a free download (.pdf or Word) at cms.gov.  ICD-9 and ICD-10 are available as complete manuals for around $100.  So, for between $200 and $250 per year, key staff and doctors could become ‘experts’ on the chat room scene real quickly.

I’ll provide a couple of examples to support my point.  One of the long-raging arguments among eye doctors; at least twenty years; has been whether the CPT definition of the comprehensive ophthalmological service (92004/92014) includes a dilated fundus examination as a requirement.  The definition has not changed since 1992 and it has never included that requirement!  The CPT definition clearly lists “…examination with cycloplegia or mydriasis” among the tests that the service “…often includes, as indicated”.  “Often includes” does not equate to “includes” or “is required.”

I think the confusion may come from the requirements for the ‘comprehensive physical examination’ for the evaluation and management services (99000 codes), but it was made very clear back when the 99000 codes were introduced nearly twenty years ago that the CPT definitions are unique and distinct for each set of visit codes and that there are no crosswalks or comparisons between the two.  In short, “external and ophthalmoscopic examinations” are required elements for 92004/92014…Dilation is not.

One of the national speakers in the medical record area continued to state that dilation was a requirement. Every year I would hear that, refer to my then current CPT book for confirmation that I was still right, and shoot off an email to suggest that the speaker ‘change his tune’.  Months later, I’d hear that the message had not changed.  Finally, early one year, with the ink barely dry on my current copy of CPT, I heard again that dilation was required.  Instead of emailing again, I picked up the phone and called. “Hey, how are you doing?  Keeping out of trouble?  Family doing fine”, etc.  After about 30 seconds of small talk I dropped my challenge.  “It’s right there in the definition”, the speaker replied. Then it hit me and I responded, “Which CPT book says that?”  “Why, the (Brand X) CPT, of course”, he parried.  FLASH!  The lights snapped on.  He wasn’t using the only official CPT book, the AMA CPT, he was using a cheap imitation, the book that continues to confuse the issues, the (Brand X) CPT!

As with so many things, we must accept no substitutes.  If I’m ever in court, I’ll want an attorney who knows the laws and, when pressed, is able to refer to the current, official statutes that pertain to the case.  I’m not going to be very comfortable if the attorney attempts to reassure me by saying that she got the information off a blog or chat room, or that he called a couple of friends or read it in a novel.  The same is true with medical records.  The care you provide had better be consistent with accepted modes of practice; the standards of care; and the medical records you keep must demonstrate clear connections between the needs of the patient and what was done, and your choices of procedure and visit codes must have been chosen by comparing the content of the chart and the definitions in AMA CPT and the current ICD listings.

Relying upon trusted resources and references can help us avoid hassles and sometimes disasters.  I know you’ve been putting this off for a long time.  Just do it today.  Get your 2015 copies of CPT and ICD-9 (and ICD-10).  Read the introductions at the front of the CPT book and the front of the 1997 Documentation Guidelines.  And then refer to those key references when questions pop up.  You’ll sleep better…You’ll find yourself chuckling quietly when you ‘listen’ in on a discussion in a chat room or read somebody’s blog…Then, without typing a response, you’ll go to the references, double check your understanding of the question, and live happily ever after.  You’re welcome.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s