Medical Coding for Stroke and Concussion Care

Optometrists have been providing medical eye care and surgical comanagement since achieving therapeutic pharmaceutical agent privileges in the 1980s and ‘90s. This development has been very important for patient access to care. For example, in our home state of Iowa, 98 of our 99 counties have an optometrist, but only 12 have an ophthalmologist.

Despite these strides in medical optometry, many optometrists find medical insurance billing to be confusing to navigate and have opted not to accept medical insurance at all. For those who are interested in providing concussion care and other neuro-optometric services, it is well worth revisiting this decision.

The need for vision therapy and rehabilitation for conditions such as stroke and concussion is great. These conditions generally are covered under patients’ medical insurance, so it can be troubling for patients to find a provider, only to discover that that provider wants them to pay out of pocket. Accepting medical insurance can be profitable for your practice too, if you learn to code and bill correctly.

DEVELOP A PLAN

Once you have decided to embrace the medical model, it is helpful to start small. Identify one medical insurance plan that is dominant in your area or common among your patient base. Complete the appropriate paperwork, obtain a National Provider Identifier number if you don’t already have one, and get credentialed by the insurance plan. See Table 1 to familiarize yourself with ICD-10 diagnosis codes relevant to neuro-optometric care.

Next, file claims for two patients covered by your target insurance plan. Ideally, choose straightforward cases rather than challenging patients who have come to you after not responding to treatments by other providers. Stroke patients are a good place to start. They want to get better, many can afford the care, and they may already have made good progress with occupational and/or physical therapy.

Do your best to code and document appropriately for these first two cases, as discussed further below, then wait to see what happens before filing any additional claims. If the claim is accepted but down-coded (ie, changed to a lower code by the insurer), evaluate why your notes might have been deemed insufficient for the code you chose initially. If you can then provide additional documentation that was missed initially, a corrected claim can be resubmitted. A careful investigation of your first few claims will help you understand the ground rules of medical billing.

From these initial test cases, you can expand to more patients and more insurance plans. It is not necessary to establish a new business entity for medical care that is separate from your cash-pay business entity.

Coding a Stroke Patient Visit

A 74-year-old patient was hospitalized after a stroke at home. She had inpatient occupational and physical therapy over the course of a 2-week hospital stay. During the discharge process, the hospital social worker referred her to us for neuro-optometric evaluation (Figure).

The initial exam included extensive review of symptoms and history of the present illness, testing, and interpretation. A full care plan for vision rehabilitation therapy was developed and discussed with the patient and family. We billed the following:

99204 – E/M code for moderate new patient visit with -25 modifier to indicate that the E/M code was separate and identifiable from other testing that day

92083 – visual field diagnostic testing code

92250 – diagnostic testing code for ultra-widefield retinal imaging (Optos) with -59 modifier so that it does not bundle into a similar CPT test code

92060 – diagnostic testing code for eye tracking evaluation (RightEye)

The patient’s care plan specified two sessions per week for 4 weeks, with an evaluation after that to determine whether to continue two per week or go to one per week. Each of the vision therapy sessions might be billed as a 99213 or 99214 examination, depending on the duration of therapy and the extent to which the doctor reviewed notes with the therapist, adjusted the prism prescription, or adjusted the care plan.

An office follow-up visit will typically be scheduled at 30, 60, and 90 days. These will be billed at the appropriate E/M code depending on complexity. The visual field testing or eye tracking evaluation may be repeated at one or more visits.

CODING AND BILLING BASICS

By licensure, optometrists can file the medical evaluation and management (E/M) codes 92000 (eye exam), 97000 (therapy), and 99000. Many insurance plans, however, will deny one or more of these types of codes coming from an optometrist. Find out which ones are accepted in your state, overall and by each insurer, and how they are paid.

In Iowa, we use the 99000 E/M codes. For an established patient with a concussion, we might code the initial evaluation as a moderate complexity (99214) examination and follow-up visits as extended (99213) or low (99212) complexity exams.

Scoring sheets can be helpful to determine whether you have met all the elements required for each level of E/M complexity. In order to code an office visit as 99214, for example, it must meet the “moderate” criteria for two out of three categories (Table 2). It should include a detailed medical history with review of multiple systems (typically taken from the intake form), a chief complaint, a history of the present illness (HPI) with at least four elements noted for the presentation and symptoms, and examination of five to seven systems or a moderate level of decision-making.

You might think that “concussion” is one element, and that listing four elements for the HPI sounds impossible, but the reality is that brain injury almost always affects multiple systems. For example, your HPI may document visual, neurologic, gait, and gastrointestinal problems in a patient with post-concussion syndrome.

In providing neuro-optometric care, you need to learn to chart like an occupational therapist, not an OD, to provide accurate substantiation for the codes you bill. Rather than making notes only on the ocular system, you should document impact on multiple systems. For example, “Lack of coordination affecting balance and gait. Difficulty with short- and long-term memory. Reading and comprehension impaired.” It is helpful to use the SOAP format, including documentation of subjective findings, objective findings, assessment, and plan.

Beyond learning to use the main examination codes, it is important to use modifiers correctly. If you have enough documentation to bill the E/M code and bill the diagnostic tests separately, that is the ideal approach, but it requires modifiers (see Coding a Stroke Patient Visit). If the exam is simple, diagnostic testing may contribute to the complexity of decision-making, and you may be better off billing a higher-level exam with the tests bundled into it.

UNDERSTAND THE PROCESS, THEN PASS THE KNOWLEDGE ON

There is a learning curve for medical billing and coding that requires an investment of time and resources on the front end. We recommend that, once past the initial learning curve, the optometrist not try to do coding and billing himself or herself, as this is an inefficient use of the doctor’s time. Instead, hire good staff, train them well, and learn to trust them.

We also don’t think optometrists should be afraid of being audited by medical insurance companies. When a healthy practice gets a healthy audit, that’s a compliment! Insurance companies simply want a billable code and documentation of the appropriate actions to go with it. When the appropriate code is chosen based not on arbitrary factors but on carefully documented care, it will be upheld during an audit. What’s more, your sick patients will be grateful that you were able to help them get better.

Providing neuro-optometric medical care can result in loyal patients, subsequent referrals, healthy practice growth, and, best of all, tremendous professional satisfaction.