Medical Records and Coding

Medical Records & Coding Service is designed to educate doctors and staff on medical recordkeeping and documentation, compliance and coding. The guidance received by the coding experts will support doctors and staff in providing the best possible patient care while ensuring accurate reimbursements are received.

Resources and support provided to AOA members include advisory and educational information related to:

  • Accurate choices of procedure and diagnosis codes for eye care.
  • Understanding and preparing for payer audits of patient care and coding.
  • Changes in Medicare and coding policies.
  • ICD-10 preparation and conversion.

2021 evaluation and management code changes—what these mean for optometry

For 2021, substantial changes have been made to coding and documentation for evaluation and management (E/M) services. This process started in 2018 when the CMS proposed a single payment rate for E/M visit levels 2-5 (physician and non-physician in office-based/outpatient setting for new and established patients). The CMS also proposed to change documentation standards and to develop an additional add-on code and bonus payment for the provision of primary care services.

The physician community, including the AOA, responded strongly to the CMS proposal, raising serious concerns with the precedent set if Medicare were to finalize such significant payment changes and ignore the Relative Value Update Committee (RUC) process for valuation of services. The RUC process allows those doctors who provide the services being valued an opportunity to provide input on the work, skill and effort involved in providing all types of health care. Following the initial CMS proposal in July 2018, the AOA was invited to meet with Department of Health and Human Services (HHS) Deputy Secretary Eric Hargan to discuss the CMS proposal. During that meeting, the AOA stressed that any E/M add-on codes for providing primary care should not be specialty specific and should be open to all physician types.

The AOA was successful in retaining that approach and the add-on code for providing primary care or caring for patients with serious conditions can be reported by doctors of optometry starting in 2021. The AOA was also engaged in the RUC survey to value the revised E/M codes and in the process to develop RUC recommendations. For 2021, the CMS has finalized its policy to utilize the CPT framework and RUC recommendations for E/M office visits. The changes will be implemented on Jan. 1, 2021 to allow time for education for use of the new guidelines and revised codes.

Key elements of E/M changes starting in 2021:

  • Effective Jan. 1, 2021, the CMS will adopt the CPT guidelines to report office visits based on either medical decision making or physician time.
  • The CMS adopted the RUC physician time recommendations.
  • The CMS will implement an add-on payment for office visits for primary care and patients with serious or complex conditions.
  • It is estimated that the add-on payment will be approximately $18 per visit.
  • Look for updates in future AOA publications. 
Medical records and coding

Online coding resources available for AOA members

AOA Coding Today is an online, comprehensive database that contains information in real time for CPT, ICD-10, and HCPCS coding and research. The website is tailored specifically to optometry, assisting doctors and staff in correct reimbursement and compliance, and has an easy-to-use code diagnosis ability based on region. Utilize AOACodingToday as a free, member resource to assist you immediately with your coding questions.

Ask the Coding Experts

If you have any questions regarding medical records and coding submit the form below.

ICD-10 Webinars and Resources

Learn more about medical records and coding with this extensive serives on EyeLearn.
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