1. Documentation Isn’t It Just SOAP?
Joe W. DeLoach, OD, FAAO
Optometric Business Solutions

2. DISCLAIMER
Let’s get it right out there – I am CEO of Optometric Business Solutions . Although I have no financial interest in the company, parts of this lecture strongly promote the services offered by Optometric Business Solutions. I think it is an exceptionally wise use of your money.

3. No…it is not and never was
So….Isn’t It Just SOAP?
No…it is not and never was

4. But let’s put something right out there…
Likelihood of getting audited
100% related to coding practices
Likelihood of LOSING an audit
30% related to coding practices
70% related to medical records documentation (Per CMS!)

5. Here Is What We Have Done Wrong
We have spent too much CE on how to make money, how to “go medical”, how to make sure your diagnosis is on the “allowed list” and not enough time talking about medical necessity, reason for the visit, coding ethics and how to really document a patient encounter! (really? OUCH!)

6. So let’s look at some “myths” of documentation that made those numbers happen

7. Let’s Start With What CPT Says Doctors Are Required To Document In A Medical Record

8. Numero Uno – Reason For the Visit
Reason for the visit is the most important concept in coding and documentation
But, reason for the visit is the most misunderstood concept in optometry
The reason for the visit ALONE determines the level of examination you conduct and the examination elements needed to address the reason for the visit

9. Misunderstood Concepts
YOU do not get to decide what level of examination you want to perform. It is dictated by the reason for the visit.
Many medical patient encounters by optometrists do not justify a comprehensive ophthalmologic examination or and rarely a Level 4 or 5 Evaluation and Management examination
You are kidding…right?

10. New patient presents with single complaint of an itchy right eye – which of the following are automatically NOT medically necessary?
Cover test
Binocular assessment
Gross visual fields
Internal, ophthalmoscopic examination
ANSWER: None of them

11. One of The Biggest Misconceptions
Most doctors think as long as they PERFORMED all the elements, they can bill a high level EM code (IV or V) or comprehensive ophthalmologic code
WRONG!
The elements you perform are dictated by the REASON FOR THE VISIT – you cannot “fit” what you do for a patient based on the level of examination you WANT to achieve (“back coding”)

12. Another recommendation...
Disable, de-preference, do whatever you have to do but get rid of the “Coding Tool” in your EMR. CMS 2012/13 Special Audit Project openly states the use of Coding Tools results in intentional up-coding and will be considered suspicious of fraud

13. Look…I Didn’t Make This Stuff Up
Per CPT:
“When determining the level of evaluation and management and diagnostic testing necessary for a particular encounter, the physician’s decision is based on the nature of the presenting problem (also called the reason for the visit)”

14. CPTs Definitions of “Nature of Presenting Problem”
MINIMAL: An encounter that does not require the presence of a physician MINOR: A problem that runs a definite and prescribed course, is transient, and is not likely to permanently alter any health status LOW SEVERITY: A problem where the risk of morbidity without treatment is low and a full recovery without functional impairment is predicted.

15. CPTs Definitions of “Nature of Presenting Problem”
MODERATE SEVERITY: A problem where the risk of morbidity without treatment is moderate; has an uncertain prognosis and there is an increased probability of prolonged functional impairment and/or mortality HIGH SEVERITY: Problem where the risk of morbidity and/or mortality without treatment is high and there is a high probability of severe, prolonged functional impairment even with treatment.

16. MYTH You Have to Have Symptoms to Bill for Medical Services
Wrong…
You have to have a medical reason for the visit

17. What can qualify as a reason for the visit
Symptoms
Patient history
Signs from the examination
Physician direction
Request for evaluation of a condition from the patient or another health provider
#2 & #3 do NOT qualify for Medicare – but do for most any other payor!!

18. Number Two – Medical Necessity
Definition (per CPT) “An item or service is considered medically necessary if it is reasonable and necessary in the diagnosis and/or treatment of an illness, injury or defect” It’s pretty easy – is the conduct of care or results of a test necessary in the care of my patient? With some exceptions, “rule out” testing not based on clinical signs is consider to be NOT medically necessary

19. Confusion
Medical Necessity The historical and legal concept of medical necessity states that it can only be determined by the attending physician Payment Policy Determination of benefit is totally the right of the payer – it’s their checkbook. More recently the terms are being used interchangeably – doesn’t matter. If you consider something to be medically necessary, someone pays for it. Benefits often do not equate with medical necessity!

20. CPT Says What About Medical Necessity
“The medical record must clearly document the medical necessity of the examination and all associated testing and treatment”
And you do that how?
Associated reason for the visit (discussed)
Complete documentation of findings (obvious)
Orders for all diagnostic tests
Interpretation and reports for all diagnostic tests

21. Testing Orders - Per CPT
“The medical necessity of the testing must be clear to the auditor based on the documentation” PROBLEM: Subjective opinion of auditor SOLUTION: Orders

22. How To Document Orders Three Places
Plan of previous visit (not best choice)
In the reason for the visit
In an EHR orders section
Ex: “Physician directed examination to monitor glaucoma status – order 24-2 OU”

23. Interpretation and Reports
REQUIRED for every diagnostic test
Do NOT have to be in a separate chart – just identifiable away from the main record documentation
No direction from CPT on requirements of I/R. Many suggest
Statement of reason for test
Brief summary of results
Statement of reliability of results or patient cooperation
How the results will influence your care of patient

24. Last Requirement - Signatures
CPT requires that patient encounters must contain a signature of the examining physician
Although not mandated, could be best if on every page of the examination (easy with most EHRs)
For a paper record, a signature is just that….your written signature – MUST be legible (or claim DENIED!). For that matter, if ALL your written recordings are not legible, claim denied. You need a Signature Page on file!

25. EHR Signatures
Electronic - “Electronically signed by Joe DeLoach, OD 9/2/13 4:30pm”
Digitized – an actual reproduction of your manual signature transferred to paper
Digital – an encryption or fingerprint that binds the doctor to the record (not ready for prime time yet!)
Signature Attestation - statement that you performed all the services (far too complex)

26. Let’s Summarize What We Know So Far You get audited by medical payer…
No MEDICAL reason for visit – claim denied
Reason for the visit not addressed – claim denied
Medical necessity not documented – claim denied
No orders for tests – claim likely denied
No interpretation and report – claim denied
No acceptable signature – claim denied
WHAT ELSE?

27. Illegible Paper Records
This one is easy – can’t read it, automatic denial
EXTREMELY difficult audit defense
Documentation will be next to impossible with ICD-10
Please join the 21st Century

28. Unclear Review of History
CPT states that on established visits, the history must be reviewed applicable to the reason for the visit. You have two choices:
Make changes, if present, to the patient’s history and hope that an auditor recognizes the changes made (without the previous record? Good luck!) Or
Make a note in your history section that you reviewed and changed the history where appropriate, and INITIAL it

29. Unclear Review of History
If the history is brought forward and you make and initial a “reviewed” statement, your level of history is credited as the same as the history you reviewed (even if it is included VERBATUM in the encounter)
The DOCTOR, not the staff must initial the review
EXAMPLE REVIEWED STATEMENT
“I have reviewed the patient’s history elements and made changes where appropriate. JWD 1/1/15”

30. Unclear or missing HPI Elements
Remember, there are eight of them:
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and/or symptoms
As a rule you always want at least four HPI elements – essential if you want to use E/M codes

31. Documenting a Contact Lens Evaluation
Bonus non-medical claim advice
Vision companies, especially the big ones, have specific requirements for documenting a billable contact lens evaluation. See the next slide for what they are!
Without proper documentation, companies will take back the contact lens fitting fee
One of the companies will take back the contact lens fitting fee AND the money your patient paid out of pocket for contact lens services

32. Documenting a Contact Lens Evaluation
History needs to include type/modality lenses worn, how they are worn, solutions used
Examination needs to document the fitting characteristics of the lenses (NOTE: Simply documenting WHAT trial lenses were used is not sufficient – need to note their fit). Also requires Ks and over-refraction
The assessment needs to state how the patient is doing with the lenses
The plan needs to state what you are doing going forward, even if that is no change

33. Another side note….
VSP and Eyemed are HOT on the audit trail for “medically necessary contact lenses” – average penalties > $50K
Medically necessary contacts are exactly what they have always been – cones, pellucids, high cyl, post surgical follies
Just sayin….A two week disposable daily wear contact lens patient overwears their lenses so you decide to fit them in daily lenses – the daily lenses are NOT medically necessary

34. EHR Template Mis-Use How do you do that?
Cited by OIG Work Plan as “significant concern for fraud and abuse”
Templates are completely legal and proper – if used properly
You need to assure that the findings recorded were actually from observations performed THAT VISIT (appropriate findings can look very similar visit to visit – not your fault)
How do you do that?

35. “Suspicious” Templates
First of all, by definition, they all are
Lack of “except as noted” language
No signed review of history
OVER or inappropriate documentation of case history (“over”- really?)
Impossible findings (best example – retinal periphery is stated as normal but patient was not dilated)
Diagnosis with no abnormal clinical findings
The obvious – EVERY chart looks the same

36. “Suspicious” Templates
Safest answer….
Make sure that on every visit you have to select to add normative findings

37. Diagnosis Without Clinical Findings
Not sure why this would ever be a problem except carelessness
Problem is, an auditor can deny the office visit and any diagnostic tests associated with a diagnosis that does not have associated clinical findings

38. Not Using the Most Specific Diagnosis
CPT coding guidelines dictate that you apply the MOST SPECIFIC diagnosis related to any procedure for which you bill services
“Snapshot in time”
Use EYE codes, not systemic codes (except code first)
Do not use unspecified codes (xxx.o or xxx.00 codes – some of most common red flags ,
(this will not be a problem with ICD10!)

39. Not dilating in Comprehensive Visit
Dilation is “usually” a requirement of the comprehensive ophthalmologic code (unless contraindicated) and always part of the internal evaluation elements of the E/M codes (NO contraindication statement)
Unless you dilate these patients or state the reason you did not, an auditor can either down-code your examination or deny the office visit all together (usual action)

40. Exceptions? Facts Opinions Abound
2014 CPT is ambiguous – For 92004/14 “usually includes”
For E/M codes, VERY clear is required to count internal exam
Opinions Abound
CPT has an “unwritten” policy of variance
CPT has NO “unwritten” policy of variance
Medical payors have an “unwritten” policy of variance
Sorry - no definitive answer. But what is the
REAL issue here – the auditor or the judge?

41. What About Vision Companies?
Vision company audits tend to be less fair and often made up on the spot. If you want to be safe, consider that vision plans will adhere to the CPT definition of a comprehensive ophthalmologic examination and require dilation unless documented as contraindicated
Dilation is usually addressed - how well do you know your vision plans

42. VSP
Dilation required for all diabetic or “at risk” patients (bs…)
EyeMed
Dilation usually considered part of comprehensive examination. Required for diabetic patients

43. “Blurred vision” as the reason for visit
“Blurred vision” as a sole reason for the visit does not constitute a medical visit unless the reason for the blurred vision is medical
Don’t believe me – call Dr. Craig Thomas and ask him how painful it is to write a check to CMS for $36,000.00

44. RECOMMENDATION
Doctor - become the coding and documentation expert in your office
Have your medical records audited by a professional company every year (new Fraud and Abuse Compliance requirement!)
Consider outsourcing your billing
“To achieve success, do what you are an expert at and outsource the rest”
Roy Spence Jr