In reflecting back over this year and the changes that have come upon us in medical coding and compliance, the overwhelming theme has been about rules, more rules, and more damned rules.

Our universe of providing eye care has changed forever and will continue to be subject to innumerable rules. Health care reform has certainly added to our regulatory burden in more ways than one, and will continue to do so. Even for someone like me who lectures on medical coding and compliance issues, sometimes it seems that the amount of research and reading that I do is analogous to drinking through a fire hose to stay on top of all the subject matter.

Get the Upper Hand
But, should this continual barrage of new rules, guidelines and regulations drive us to behave like the ostrich? I hope not, because hiding your head in the sand will not make any of these things go away. The answer lies in being proactive rather than reactive. Those practices and practitioners who adopt internal strategies and tactics focused on embracing change, rather than avoiding it, clearly have an upper hand.

Fortunately, many of you are in this camp. In my travels around the country, I see a significant groundswell in those who understand that seeking out, learning and following these rules, guidelines and regulations helps to provide better clinical care, increase revenue from eye care services and reduce risk.

Unfortunately, there are also some providers in our profession who believe that the rules don’t apply to them, because they don’t follow the “medical model,” or that they just provide refractive care—or, worst of all, they’ve just thrown their hands in the air in frustration and given up.

Make 2013 Your Year
I must get one or two phone calls or emails per week from O.D.s who are being audited by a carrier, whether medical or refractive, with a stated restitution of six figures. That was unheard of just a few years ago, but this is the reality of today. In my efforts to assist colleagues who are going through audits, one thing is clear to me: It is the rare exception when a provider intentionally tries to defraud a carrier. In my experience, most optometrists caught in this situation simply don’t know the rules surrounding medical charting and the subsequent CPT coding and billing for professional services and materials.

To illustrate a common example of this, most O.D.s were taught to perform one kind of eye examination—a comprehensive exam—even if the patient’s presentation doesn’t justify it. However, in the health care system of today, it’s important that you perform an exam that’s commensurate with the presentation of your patient. So, if you’re following a patient with a specific disease state, perform an examination that focuses on the ocular elements of that disease. (This is one of the true benefits of using the 992XX E&M codes rather than the 920XX codes—they allow you to tailor the examination for the specific structures of the eye that are pertinent to the disease state, rather than just automatically performing a comprehensive exam without appropriate justification in the record.)

So, as 2012 comes to an end, here’s my simple message to all of you: Make 2013 your year to embrace the ongoing changes in health care. Make 2013 your year to use modern, up-to-date resources to stay informed. Make 2013 your year to make a plan to integrate and implement these changes into your practice. And most importantly, make 2013 your best year ever—as we come to realize that the most reliable constant that we have in life…is change.

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