Billing and coding is a minefield of changes, and it’s hard work to stay apprised of current information, rules and regulations. But when we get complacent and don’t keep up, it often contributes to a lazy attitude about billing and coding. Rather than learn the rules or use technology to help keep the practice compliant, human nature—or optometric nature—often turns to rationalizing the behavior rather than changing it.

Worse yet, when challenged on coding habits or patterns, practitioners often get defensive and make excuses. “I heard about this from a friend,” “I was told that if I used this code, I could get paid more” or “my sales rep told me to do it this way,” are frequent reasons why a practitioner has been using a particular coding pattern. Keeping current with the torrent of change is a difficult task, and many get lulled into a state of complacency, just because they got paid.

Getting paid for a code is never a good defense for a particular coding or practice pattern. Your only defense is knowing that your medical record demonstrates the care delivered was the care required by the patient. Though, I must admit the stories are interesting.

You Can’t Make This Up: Ignoring The Facts

Here is a situation that highlights just how easy it can be to rationalize a wrong coding behavior:

Dr. X: How much do you charge extra for dilation?

Coding expert: Dilation is included in the definitions of both comprehensive ophthalmologic and EM codes. You can’t charge extra.

Dr. Y: You can charge extra for a medical dilation.

Coding expert: There is no CPT code for a “medical dilation.”

Dr. X: Yes, there is, 92225. Also, you can have them return and charge the dilation as a cycloplegic refraction since all dilating drops have cycloplegic action.

Coding expert: 92225 is a separate procedure for extended evaluation of serious retinal conditions. It is not used to bill for dilation, which again is part of the medical office visit. Charging for a refraction that way is no different than charging for a photo when you really used a scanning laser. That is fraud.

Dr. Y: Totally wrong! We bill 92225 or 92226 in addition to every office visit during which we dilate. We have done it for years and always get paid. 

You Can’t Make This Up: Fabricating The Facts

Each CPT code includes an entire set of characteristics that you must adhere to when providing the service. The medical record must explicitly explain the patient’s chief complaint, your clinical assessment, your diagnosis, additional tests you ordered or performed (and why) and your recommendations for further testing or treatment.

A chief complaint (or reason for visit) is not inferred. If it is not recorded in the record, it is not there. You cannot say that a history of present illness is a chief complaint, or that the previous visit’s instructions are the chief complaint, unless specifically written as such. Medical necessity must be explicitly stated for each and every additional procedure or test you perform. You cannot fabricate facts or rely upon patterns of practice to fulfill the factual elements required by the CPT. 

An example: During one audit, the practitioner was flagged for excessive use of special ophthalmic procedures three to four standard deviations away from the mean used by his peers. He claimed he did every test on every patient to “do a thorough job”—how could he find every issue unless he tested? Fabrication of the facts like this is the first step of rationalization and puts you down the path toward complacency.

Health care today is dynamic, confusing and sometimes just too much information to process. But that’s no justification for denying the rules exist or rationalizing that they don’t apply to your situation. This not only makes you complacent in your approach to each patient, but also how you record encounters and code them for revenue generation. 

It is a slippery slope that you don’t want to be on. Provide every patient the care they require, and properly translate your record to reflect the true definition of the CPT codes you are using to bill for services provided.

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