With today’s technological advances, we can diagnose glaucoma earlier and treat it more effectively than ever before. However, for many, diagnostic testing protocols for glaucoma often consist of many more tests than are called for in the American Optometric Association’s (AOA) Clinical Practice Guidelines and the American Academy of Ophthalmology’s (AAO) Preferred Practice Patterns.1,2
A protocol is nothing more than a toolbox of clinical tests, not all of which are necessary for each and every patient. Rather, you must selectively use the tools that are most appropriate for each presentation. These easy steps will keep you at the cutting edge of diagnostic prowess and keep you and your practice safe.
1. Establish Medical Necessity
Your medical record must clearly state why each test ordered and performed meets the requirement for being medically necessary. Tests are not deemed necessary just because they are part of a protocol or because they garner additional, confirmatory information.
Additionally, each of your contracted medical carriers may have a specific clinical policy they have approved for appropriate clinical care. If a required test is not covered by the carrier’s medical policies, follow the appropriate rules to complete an ABN form with the patient prior to the test to preserve your rights of compensation.
2. Complete the I/R
Diagnostic tests are not billable until their interpretation and report (I/R) is complete. You cannot create a “master” I/R for all diagnostic tests; rather, each test and I/R needs to stand on its own, and the record should reflect this. An I/R should contain the clinical findings, test reliability, comparative data (if applicable) and clinical management.
3. Respect the CCI Edits
Correct coding initiative (CCI) edits are a set of federal rules carriers follow that stipulate what CPT codes can be performed and coded for on the same date of service. They exist to preserve standards of care and help with coding consistency nationwide for specific disease states.
If you are going to violate a CCI rule, your medical record should demonstrate that it was imperative to do so, and you must use appropriate CPT modifiers to further define the clinical situation that forced you to violate a rule.
Often, I see scenarios where a clinician performs two tests that are not allowed to be performed on the same day, and they choose to not code for or charge for one of the services provided. This is not an acceptable practice and puts you and your practice at risk.
4. Use ICD Properly
The ICD-10 rules are rather unforgiving. As with your insurance provider agreements, they stipulate that you must code to the highest level of specificity of a disease state that the individual patient has. Fudging a diagnosis to get a test covered could easily be construed as fraud. Make the time to learn the ICD-10 rules—they are far more important beyond getting paid for your clinical care.
5. Embrace Technology, But Know Its Limits
Much of the newer technology introduced for faster, easier and more accurate diagnosis may not be included in the AOA or AAO clinical protocols and may not be included in your carriers’ covered testing policies. In addition, many CPT coding changes within the last few years have changed the definitions of some tests, as well as the category of CPT codes, all of which can affect your coding accuracy and subsequent reimbursement.
By following these five steps, you will provide the appropriate care on the appropriate date of service, and you won’t perform the same battery of tests on every individual with the same ICD-10 diagnosis. The more discerning you are and the more detailed your medical record, the greater chance you will be properly paid and safe from audit.
Send your own coding questions and comments to firstname.lastname@example.org.
1. American Optometric Association. Glaucoma Clinical Practice Guidelines. www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines. Accessed May 24, 2019.
2. American Academy of Ophthalmology. Primary Open-Angle Glaucoma PPP – 2015. www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-ppp-2015. Accessed May 24, 2019.