Medical Decision Making Arteritic Ischemic Optic Neuropathy

So now I want to get into reviewing a few case examples so that we’re able to work through this and Gilan, I’ll give you a case and if you’ll walk us through your approach on medical decision making utilizing the new guidelines. So, the first example we have is an arteritic ischemic optic neuropathy.


So, Maritza as you know, it’s a fairly low percentage of the time that optometrists are involved in coding something at a level five, but I really wanted to start this with a couple of examples that are seen in optometry offices that definitely would qualify for level five coding. And so the first one would be giant cell arteritis or arteritic ischemic optic neuropathy. If we take a look at our medical decision-making grid and we start over at the element one, at the number and complexity of problems addressed, we’re only going to have maybe here. But it’s an acute or chronic illness or injury that poses a threat to life or bodily function, which of course, this is doing both. Certainly, it can lead to death and or extreme morbidity. It actually already is an extreme morbidity and definitely causes loss of vision. So easily qualifies in the high category on the first element. On level two, that data complexity as you note there, we’ve got three categories. We’ve got tests, documents, or independent historians. Any combinations of those three, of those three categories. And we’ve got category two, independent interpretation of tests. And category three, discussion of management or interpretation and we’ve got to meet at least two out of the three of these categories. So, let’s just start with category three, that’s probably going to be easy because most of us are probably going to have the conversation with another physician about the patient’s management. So, that’s one of the components. And now, if we’re looking at independent interpretation of tests, performed by another physician or qualified healthcare professional, that may happen cause we’re probably going to have to look at the first category. We’re going to order multiple unique tests. I’d say at the very least the average optometrist is going to order an enrichment sedimentation rate and a c-reactive protein. Those two unique tests and were going to review the results from those tests when we get them back from the laboratory. So, now we’ve got two of the bullet points addressed there. We may have an independent historian, depending on the cognitive awareness of the patient involved there. So we may meet it right there. And then the first bullet point about external notes from a unique source may meet that if that patient was referred to us by another provider. So, we have an opportunity to have that be in the high complexity level even on the complexity of data reviewed. Now, we may be the initial provider and we may be the initial person ordering those unique tests, however, those tests are going to be done outside the office. We might have trouble meeting category one if we are the initial presentation point. We’re going to meet two of those bullet points fairly easily with your review of results from unique tests and ordering tests, but we may not need assessment requiring an independent historian. So, we might have trouble meeting that. The independent interpretation of tests, we may have those done by another physician so we might not meet that. We probably are definitely going to meet the discussion of management or test interpretation, so that’s going to drop us back into a level four for that particular element. Keep in mind that when we are finished though, we’ll throw out the lowest one and bill on the next lowest one. And so now if we go over to risk of complications and or morbidity or mortality of patient management and we’ll review the requirements for high risk of mobility some additional diagnostic testing of treatment, we certainly are going to have that just with the drug therapy depending on the type of steroids used, depending on tests that we order. You may order a temporal order biopsy and that might not be considered to be major surgery, it’s definitely not elective. And it’s maybe not even considered major and the patient may be determined to need hospitalization if the disease is far enough progressed. But definitely were going to meet drug therapy requiring intensive monitoring not only for toxicity but for resolving the disease. So, we’re going to throw out potentially the data complexity and bill based on our risk of morbidity and mortality in patient management with both high risk of morbidity and mortality certainly with giant cell arteritis and then obviously we have met the number of problems and problem complexity easily with our acute chronic illness or injury that poses a threat to life or bodily function. So, this would be an example of a fairly easily determined level five code.