Thorough documentation in an ophthalmic chart note is instrumental in both patient care and accurate billing and coding practices. It helps eyecare providers make precise diagnoses, tailor treatment plans effectively, and adhere to proper billing and coding guidelines.
To answer some fundamental questions about comprehensive documentation and how this can best be achieved, including ways to effectively integrate this information into chart notes, Judy Williams, president of BSM Consulting, sought insights from industry experts Brenea Facchini and Brittney Irwin.
Judy Williams: What key elements should be included in an ideal eye-care chart note?
Brenea Facchini: The ideal chart note starts with the chief complaint (CC) and history of present illness (HPI). It truly drives the exam, and this is where new or poorly trained technicians really struggle. Often, I find technicians asking the same questions for every work-up type, and you end up with very generic CC/HPIs that do not give the provider or the payor enough information. The CC should be the reason for visit, for example, “6-Month Dry Eye Follow-Up” or “Diabetic Eval.”
I would strongly discourage techs from using “Routine vision exam” or “Patient requesting new glasses” as a chief complaint. Instead, focus on why the patient wants new glasses: Is it because they are noticing blurred vision? In that case, I would use “Blurred vision” as my CC and expand on the symptom in the HPI. The HPI should include symptoms, location, etc. I would advise staying away from anything refractive, such as “broken glasses” or “wants new glasses Rx,” which establishes a refractive visit that may not be covered by medical insurance.
Brittney Irwin: Great tips! It is also important to remember that the reason for the visit (CC and HPI) determines whether the encounter is billable. The Medicare Transmittal 18021 states the following, “The coverage of services rendered by an ophthalmologist is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to an ophthalmologist with a complaint or symptoms of an eye disease or injury, the ophthalmologist's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her ophthalmologist for an eye examination with no specific complaint, the expenses for the examination are not covered even though because of such examination the doctor discovered a pathologic condition.”
Williams: What information is essential for a dry eye patient’s chart note?
Facchini: During the initial work up, the technician should document a thorough HPI that includes dry eye symptoms and at-home treatment regime. If punctal plugs are the next step, then the HPI and/or plan should include what treatments, if any, the patient has tried and failed — for example, artificial tears (ATs) (how many times a day on average), Restasis, warm compresses, etc. I would suggest scribes include whether a sample of ATs were given and how many times a day the doctor suggested using them. If possible, avoid “use artificial tears as directed” and try to be more specific.
Irwin: Also, if the patient complains of dry eye, it might be beneficial to ask your provider whether you can perform a Schirmer’s test to help with documenting medical necessity for future treatment. As Brenea mentioned, the chart documentation must provide medical necessity for punctal plugs. The retired First Coast Local Coverage Determination (LCD) Lacrimal Punctal Plugs (L33916)2 states the following:
Lacrimal punctal plugs will be considered medically reasonable and necessary for patients with the following:
- Symptomatic, moderate, or severe dry eye syndrome when more conservative treatments (i.e., artificial tears) have proven to be ineffective; and
- A diagnosis of aqueous tear deficiency has been confirmed by:
- One or more of the following diagnostic tests: tear break-up time (TBUT), Schirmer test, ocular surface dye staining pattern (rose bengal, sodium fluorescein, or lissamine green); and
- Slit-lamp biomicroscopy exam.
Williams: What key information should be present in a diabetic patient’s chart note?
Facchini: The CC/HPI should include the most current A1c results, along with the most recent blood sugar reading (fasting if possible). The patient should be asked about any intermittent blurred vision that may correlate with spikes in blood sugar. Many providers suggest deferring a refraction until blood sugars are under 200 for 2 weeks, as elevated blood sugars can cause a temporary refractive change. Ensure the tech or scribe has updated the managing diabetic doctor (primary care physician or endocrinologist), as they will need to receive a letter with the results of the examination.
Irwin: The scribe and physician should work together to ensure the chart documentation (posterior exam and impression/plan) reflects the most accurate diabetic ICD-10 codes for each eye respectively. Then the claim can accurately link the diagnosis code with the corresponding diagnostic test or procedure, helping to avoid a denial.
Williams: What key elements should be documented for cataract surgery?
Irwin: The Medicare Administrative Contractors (MACs) apply the standards in their respective cataract surgery LCDs and corresponding Local Coverage Articles. The policies for each MAC are similar but not identical. However, they each recognize the following fundamental medical necessity criteria:
- A specific compromised activity of daily living (ADL) (e.g., driving at night, reading, etc.)
- Documentation that the cataract is the primary reason or a significant cause of the visual impairment
- Best-corrected visual acuity (BCVA) from a manifest refraction (MR)
Additionally, several practices have received Targeted Probe and Educate (TPE) audits with claim denials because there wasn’t an attestation that “the patient’s impairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses”3 in the beneficiary’s chart.
Facchini: Therefore, I suggest performing routine internal audits on cataract evaluations to ensure technicians are documenting a specific compromised ADL in the CC/HPI, a BCVA established by an MR and a glare test, if necessary, and according to your provider's preferences. The impression and plan documentation should also include a statement that the compromised ADL is not improved or resolved with a tolerable change in eyeglasses or contact lenses. Truly, the scribe should be the final reviewer of the chart to ensure medical necessity is documented prior to the completion of the examination.
Williams: Does the surgeon need to pre-plan complex cataract surgery to be able to bill Current Procedural Terminology code 66982?
Irwin: The MACs don’t specify that complex surgery needs to be pre-planned. However, they do expect a justifying statement in the operative report to support the need to employ devices or techniques not generally used in routine cataract surgery.4 Several MACs also list examples, such as, but not limited to, a Malyugin ring used for a poorly dilated pupil or trypan blue for a mature dense cataract.5
Williams: What key documentation is needed for an in-office procedure? What if it was pre-planned? Do we still need a chief complaint?
Facchini: The CC/HPI should reflect a complaint appropriate for the procedure ordered. If during the discussion with the doctor the patient addresses new complaints, then the scribe should update the CC/HPI accordingly. If the patient is here for a procedure only, without a billable office visit, then I would typically create a CC reflecting why the patient is here, such as “RUL biopsy” or “YAG Cap OD,” and exclude an HPI. If the patient presents for a procedure-only visit, then the tech should ensure a signed consent form is on file prior to the procedure.
Irwin: Make sure your procedure note contains the appropriate documentation. If the patient is receiving an injection (intravitreal, Botox, etc.), the procedure documentation should include the drug waste or have a statement about no waste being discarded. With the introduction of the -JZ modifier in 2023, CMS now expects to see either the -JZ modifier or the -JW modifier on the claim for single-use drugs, including single-use syringes of intravitreal medication.6
Williams: Can we bill for an office visit on the same day as the procedure?
Irwin: The Medicare Learning Network (MLN) Global Surgery Booklet7 states: “The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier '-25' is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.”
Ultimately, it depends on your chart documentation. If the sole reason the patient is sitting in the exam chair is the need for minor surgery, then modifier -25 likely does not apply. Conversely, if there is another problem being addressed (at a medically appropriate interval), then, depending on your chart documentation, modifier -25 with an office visit could be billed.
Facchini: For example, if a patient has glaucoma and dry eye, two separate CCs/HPIs can be created. Consider a patient being followed for glaucoma; CC/HPI No. 1 could read as “4-Month Glaucoma Follow Up patient compliant on Lumigan QHS and denies any trouble with the drops,” and CC/HPI No. 2 could state “Worsening Dryness, has tried and failed artificial tears and Restasis. Patient scheduled for BLL punctal plugs today.” This documentation, as well as an appropriately documented impression and plan, would help justify medical necessity for the office visit with modifier -25 and the punctal plug procedure. OP
References
1. Medicare Carriers Manual Part 3 – Claims Process Transmittal 1802 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1802b3.pdf. Accessed May 9, 2024.
2. Retired First Coast LCD - Lacrimal Punctal Plugs (L33916) https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=33916:4&keywordtype=starts&keyword=punctal&bc=0. Accessed May 10, 2024.
3. Palmetto LCD – Cataract Surgery (L34413) https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34413&ver=51&keywordtype=starts&keyword=cataract&bc=0. Accessed May 14, 2024.
4. Noridian LCA - Billing and Coding: Cataract Surgery in Adults (A57195) https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57195. Accessed May 9, 2024.
5. First Coast LCD – Cataract Extraction (including Complex Cataract Surgery)(L38926) https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=38926&ver=23. Accessed May 9, 2024.
6. Medicare Program Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy Frequently Asked Questions https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf. Accessed May 13, 2024.
7. Medicare Learning Network Global Surgery Booklet https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/globalsurgeryicn907166.pdf. Accessed May 10, 2024.
