Coding

In Coding, Documentation is Vital

Improper health insurance coding documentation accounts for far too many instances of coverage denial and fraud accusations.

By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA

Welcome! Ophthalmic Professional is starting a new column. Each issue will feature either Patricia Kennedy or myself presenting you with material on coding and reimbursement. Our goal is to give you timely information to actively help you with this often-confusing subject.

Coding knowledge may seem like an obvious job requirement now, but 15 years ago I wouldn’t have thought as much. Our job, I thought, was simply to “take care of patients” and coding was for the insurance staff. Like it or not, it’s incumbent on technicians to know general coding principles. Our position on an eyecare team uniquely qualifies us to help our practices. The rules don’t change much over time, but they do change. Some of these changes, such as ICD-10, will have tremendous impact and require planning. The documentation you provide will be critical when ICD-10 is enacted.

The Biggest Mistake

The single biggest problem I encounter in chart reviews is weak documentation. It may not seem fair that a missed item alters coding options, but it’s an unavoidable fact. Insurers insist on proper documentation, but they are not the ogres we sometimes think. They don’t mind paying for appropriate care. They won’t pay, however, when care seems inappropriate. Documentation is often the difference.

There are, fortunately, only a few differences between the various payers. It is not enough for technicians to know the rules exist. If information is missing, our coding options and payments suffer. We must realize that healthcare funding is finite; the future will have fewer providers but more patients. There may be constraints on access to care since we can only work so many hours or so efficiently.

While recent Medicare ads encourage patients to report fraud and abuse, my experience is that weak documentation or poor communication is behind most issues. Outright fraud is uncommon. The adage “not written, not done” has never been truer! A payer who can’t see what was done may deny claims or ask for more information (documents).

The Information You Need

We’ll give you the information you need. We’ll review new or changed codes. We’ll also keep you abreast of regulatory changes and give you insight into issues that are receiving increased scrutiny.

Patricia Kennedy, COMT, CPC, COE is your column writer for next month; she and I are sharing the column duties. I am confident you’ll enjoy the material; Patricia’s insight and knowledge is considerable.

We also want your input! Tell us what’s giving you difficulty or suggest future topics. Contact us Ophthalmic Professional’s senior associate editor Bill Kekevian at william.kekevian@springer.com.

“Good coding” to all of you! OP

Mr. Larson is an associate consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.