Change always brings adaptation, some good and some bad. When I see individuals trying to game the system, basing clinical decisions on reimbursement rather than appropriate clinical care, it worries me.
While reimbursement is a critical component of the clinical paradigm, it isn’t one that you can hang your hat on to bring defense in an audit. Auditors will always examine the clinical care required by the individual patient’s situation and whether the physician performed the correct care by what is recorded in the medical record. An auditor will define the care properly by using the correct CPT code, and determine whether or not it fulfilled the definition of the CPT code with respect to medical necessity and clinical element requirements.
My advice: Always put patient care first. Keep current in knowledge and understanding of the CPT code set that describes the services you provide, and make sure that everyone in the office who touches the clinical record understands those requirements and definitions as well. Do not base clinical decisions simply on reimbursement from a third-party carrier. Much of the care that ODs provide is still paid out of pocket by the patient despite being “covered” due to the prevalence of high-deductible healthcare plans in the marketplace.
Be sure that when looking at the retina, you are following the guidelines, requirements, and definitions of the two new codes for extended ophthalmoscopy.
CPT Professional Edition, American Medical Association, 2019, pg.650
CPT Professional Edition, American Medical Association, 2020, pg 658