Diabetes and its accompanying ocular manifestations are among the most common disease states in the optometric practice. Within this presentation lies great opportunity to help patients proactively with regular examinations and diagnostic procedures—but it also holds the temptation to see the patient as a bank account due to the frequent number of visits and the potential for over-testing.
Know the ‘Medical Necessity’
Before we get into the specifics of diabetes and the special testing that comes with it, let’s revisit the concept of medical necessity. Medicare’s website defines “Medical Necessity” as: “Services or supplies that are proper and needed for the diagnosis or treatment of the patient’s medical conditions, are provided for the diagnosis, direct care and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or the physician.”
What does that mean in practical application? It means that the patient’s medical record must clearly demonstrate that the service, procedure or test ordered was absolutely necessary to diagnose, treat or monitor the patient’s condition.
Diabetes is one of the few diseases for which the Centers for Medicare & Medicaid Services (CMS) has adopted a true philosophy of preventive care. For example, in 2008, CMS allowed the provision of an annual comprehensive eye examination (92004/92014) solely with the systemic diagnosis of diabetes (250.XX) even in the absence of diabetic retinopathy. This is the only systemic condition (that I’m aware of) for which an annual comprehensive exam is allowed without apparent ocular complications.
Two Things to Watch For
One of the most common mistakes that O.D.s make for individuals with diabetes is ordering many special ophthalmological procedures simply because the patient has a diagnosis that can be tied to these procedures. Unfortunately, this compulsion for further testing is often unwarranted.(Simply having a “covered diagnosis” does not equate with the medical necessity of the test itself. For example, fundus photography may be a covered procedure when accompanied by the diagnosis of diabetic retinopathy—but only when the clinician actually sees a change that meets the definition of medical necessity as it relates to the patient’s specific case.)
This compulsion can then turn into angst when the carrier requires a review of the records to determine the medical necessity of all of the testing performed.
When O.D.s in such a situation contact me, I ask why they ordered the test in the absence of clinical information. The usual response: “Because I was afraid of missing something.” The doctor is well intentioned, but misinformed.
Here’s the bottom line: Your patients’ medical insurance is not the same thing as your malpractice insurance. Ordering and performing special ophthalmological tests in the absence of establishing medical necessity for those tests in the medical record is simply inappropriate, and the monies paid by a carrier are definitely recoverable in a post-payment review.
The other area that requires special attention is the interpretation and report. This document must contain specific information about the reason why you ordered the test, your specific interpretation of the test results, a comparative analysis with previous test results (if any) and, most importantly, how the test impacted the course of care and outcomes for the patient. Properly done, an interpretive report in itself tells the story of why the test was ordered and performed, and what it added to the care profile of the patient.
Diabetes is a very common disease state, but unique in the preventive care allowed in the eyes of medical carriers. If you concentrate on taking care of the patient, rather than allowing the temptation of economics or fear of medicolegal jeopardy to drive decisions, and if you make sure that your medical record is meticulously documented and accurately reflects the “what and why” of the care you provided, then the medical coding of the case will take care of itself.
