Coding

Documentation for “Second” Eye Surgeries

Cutting corners can prove costly to the practice.

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

Most of us know how to properly document the functional complaints that justify the medical necessity for cataract and YAG capsulotomy. The same level of documentation applies to each eye. While that seems straightforward patients may inadvertently not properly justify the need for the second eye surgery.

Improper documentation

Does the chart in Example 1 look like a common right eye one- or two-week post-op cataract surgery visit?

A careful reading of this note shows that the plan to “proceed” isn’t really supportive for medical necessity of the left (second) eye. This note essentially says that doing surgery on the first eye fixed all the problems for this patient and that the patient wants to pay for the second eye. We know that’s rarely the case. In fact, when asked about the “other eye,” patients often note it seems much worse, not better. Other issues present in that note are:

■ The HPI confirms the CC which says there are no problems (by not noting the eye).

■ Visual acuity is not noted as “with” or “without” correction.

■ Parts of the exam are left out entirely.

■ The exam, Dx, and Plan only speak to the post-operative eye.

Example 2 is a better note for this visit. It provides greater clarity and proper medical necessity for the left eye cataract surgery:

Justify each eye

Even if you provide justification for the left eye before the right eye was done, that’s not enough for the payer. You need something in the chart after the first eye confirming that the functional complaints of the other eye are unresolved (or note any new or worsening issues) to provide clear medical necessity for the second eye. Remember, these documentations apply to procedures we do sequentially, such as YAG capsulotomy.

Nearly all payers use the AAO’s Preferred Practice Patterns (PPP) in their reference list for coverage policies. In this case, AAO has one titled “Cataract in the Adult Eye”; the most recent revision was made in 2011.

The PPP states “The primary indication for surgery is visual function that no longer meets the patient’s needs” and goes on to state: “Studies…concluded that patients who had surgery in both eyes had greater improvement.”

While you may think the latter quote is more important when your wish is to maximize vision, the PPP notes also:

“The indications for second-eye surgery are the same as for the first eye.”

Don’t forget that each eye needs its own justification at the proper time.

Double check your notes

I am aware of payers who have successfully recouped monies paid for second eyes when the notes are weak, such as in Example 1. Here are some ways we can we avoid returning monies to payers:

■ Document the functional limitations of the patient as though the other eye does not exist.

■ Be sure the exam(s) notes the status of each eye; it helps to think of these as “separate exams” with separate needs.

■ Be sure to watch your payer polices for documentation requirements regarding “second eyes” (such as imbalance or disabling diplopia). If not specifically referenced, the policy in effect must be met for each eye individually.

■ Think of other possibly sequential surgeries in like manner (such as YAG capsulotomy).

As always, “good coding” (and in this column, “good documentation”) to all of you! OP

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