Uncontrolled Glaucoma

And Dr. Cockrell if you could walk us through a patient with uncontrolled glaucoma for our next case example.

So, this is a great case Maritza and it’s a little bit contingent on did the patient initially present, is this an initial presentation or is this a follow up visit? Either way, the patient is uncontrolled. So, we’ve got a level four in element one the number and complexity of problems addressed. We fall into level four immediately with one or more chronic illnesses with exacerbation, progression, or side effects of treatment. So we’re going to have progression that's uncontrolled. And then when we get over to data complexity, we easily may fall into moderate there as well. We’ve got to meet one of three categories. So, if it's uncontrolled, we’re probably going to discussion management with another physician and we’ve met the requirements for moderate already. We may meet the requirements for moderate which would external notes from a previous physician or optometrist and review of the results. We could need an assessment requiring an independent historian, most likely not. And then ordering each unique test, that's a debatable topic and hopefully that will become more clear as this is discussed or debated or tested over the next few months. Again, if the act of ordering the test is separate from the act of performing the test, we may meet that category. It may not be important, this particular element may not be important in our, in coding because we may discard that. So we obviously jump right into moderate risk of morbidity and because we’ve got prescription drug management or the alteration of current prescription drug management, so we fall easily into level four. If that’s a new patient, but even on some follow up visits it’s still going to be a level four. Where many times, in my own practice, in the past and you know arguably, I didn’t code this as well as I should have, but I might code that patient a level three when they’re obviously a level four based on new criteria. So, thank you Maritza. 

Thank you. And if you could also discuss if the patient presents with a closed angle in your office, how that would be coded a little differently. 

Closed angle, certainly is a more complex issue. So, we’re still one problem with complexity addressed gets higher immediately. We drop right into one acute or chronic illness or injury that poses a threat to life or bodily function. So, obviously we’ve got a threat to sight. So the first element, we’re into level five. Now in the second element, we're going to meet category three, probably right away. Probably going to have a discussion of management or test interpretation with an external physician. We’re going to meet that easily, but only one out of three categories. We may have external notes from another source, if the patient was referred, maybe they tried to do a test or may have ordered a test that we’re reviewing, we may have ordered tests, but they were inside our office; and we're still under that purview of is the act separate from the performance of the test. However, when we get over to risk of complications and morbidity from mortality from treatment, we’re dropped easily into a level five. We’re going to have drug therapy, maybe Diamox, we have risk of systemic health consequences, maybe life altering consequences with it. We might use Diamox, we might use other medications there for systemic and going to potentially create problems. We’re certainly going to initiate other treatments along with potentially surgery that would fall into the minor surgery definitions according to the AMA if we’re using a laser peripheral iridotomy. So now we throw out the second element and code to the lowest of the final two. We’re still at a level five. So if I have a closed angle glaucoma patient in my office, and in this particular year, I’m going to code that as a level five and I believe that my documentation can easily defend that level of coding. You could potentially down code that to a level four if you said it’s one undiagnosed new problem with an uncertain prognosis. And you're probably going to fall into a moderate level four with a data complexity and then easily level four or level five on the risk of complications. And so you would throw out either one of the moderates and bill to the other. So, you could make an argument for billing this at a level four, depending on the patient and the history and maybe the response to my immediate treatment with where I'm trying to break the angle closure. If I don't have to use the systemic drug, then I might code that as a level four. But if I’m having to get into ordering Diamox or something like that to lower the pressures, then I’m at a level five. You all may code that a little bit different and I certainly wouldn't argue with that, but that's the way I would do it and I have broached the subject with a couple certified professional coders and one certified professional auditor.