Tips on glaucoma billing aim to maximize reimbursement

Madison, CT-Common errors related to billing for glaucoma patients may have detrimental effects on the financial success of an ophthalmology practice, said Donna M. McCune CCS-P, COE.

"Glaucoma patients are often the bread and butter for your practice income, and ophthalmologists who render excellent care deserve to be paid fairly for their services. In reviewing glaucoma billing, however, we often find a number of issues that preclude maximum reimbursement," noted McCune, vice president, Corcoran Consulting Group, a practice management consulting firm that specializes in reimbursement issues for ophthalmology and optometry practices. The company is headquartered in San Bernadino, CA. McCune is based in the Madison, CT office.

Some of the most common problems relating to billing for glaucoma patients involve documentation and coding errors.

Poor history. McCune said that not uncommonly, the level of service rendered cannot be satisfied due to an incomplete or missing medical history. Areas requiring attention include updating, accuracy, and completeness.

"Glaucoma patients are seen frequently over a prolonged period and there should be a protocol in place to update the history when medically necessary or at least once a year. The history should include all pertinent positives and negatives, dating of any changes to the original history form, and use of a new form to enter any major updates," she recommended.

Poor chief complaint. The chief complaint provides justification for the billed level of service and should represent a fair statement of the purpose of the patient's visit. In establishing the chief complaint, the ophthalmologist should not overlook the opportunity for staff teamwork to collect the necessary information.

"Glaucoma patients may come to the office complaining of some other problems that may lead to a more complete exam in order to establish the diagnosis, and it is important to record that information," McCune said.

Poor consultation report. Glaucoma specialists see many patients on consultation. A completed consultation report should be sent to the referring physician in a timely manner, preferably within 72 hours, and should contain "who, what, why" information in the first paragraph that justifies the consultation. In addition, the chief complaint should reflect that the patient was seen for a consultative service.

Missing/tardy test interpretation. McCune reminded ophthalmologists that interpretation is a necessary piece of the documentation to receive reimbursement for diagnostic tests. It should be signed, appear in the patient's record as a distinct piece, and preferably be completed before the claim is filed. The interpretation should include information on the reliability of the test and the findings, but also contain an assessment and comments on implications.

Repeated testing. Concerns about failure to receive reimbursement for repeated testing on the basis that the payer considers the frequency too aggressive are justified and should be addressed by ensuring there is adequate documentation supporting the rationale for ordering the test. That might include the description of such factors as presence of new symptoms, disease progression, treatment failure, or necessity for formulating a new management plan. As a safety net when concern exists, practitioners might also ask patients to sign an advanced beneficiary notice so they will be held financially responsible if reimbursement is refused.

Lack of support for high utilization. McCune also advised practitioners to monitor their utilization and compare it against available statistics.

"Looking different from your peers with respect to office services, clinical services, or diagnostic testing represents an area of exposure for a practice. Therefore, be sure you have recorded a reason to justify the services and that the medical necessity is clearly documented," she said.

Coding errors

Incorrect level of service. Selection of incorrect level of service is a common coding error. In that regard, ophthalmologists often miscode their E/M services, and usually to a lower level. They also tend to avoid level 5 codes due to concern that documentation is insufficient to receive reimbursement.