Using the features of EMR and practice management software can help you code your examination more accurately both on the diagnosis side and the procedural side. For example, using just the Code Complete function in the MaximEyes®software from First Insight can help your efficiency, reduce coding errors, and help you review the entire exam.
Eliminate Coding Errors
Code Complete can review all of the data input during an examination and then suggest proper ICD9 and CPT codes based on that data. For example, if it finds flakes listed under lids it will suggest blepharitis. It will also review all refractive data and suggest the proper ICD9 codes for refractive errors as well
Code Complete is even more powerful in that it can also suggest CPT codes based on the
exam data input. For example, it can code FB removal if you indicate an FB is located on the cornea. How about coding epilation if you note a turned eyelash? You can see the power of being able to automatically code both CPT and ICD9 codes this way. It can save you significant time at the completion of an examination.
100% Customizable
The real advantage of Code Complete is that it is 100% customizable. Therefore, you can
link any terms you want to ICD9 or CPT codes. For example, I might link A/V nicking to hypertensive angiography, and you might link A/V crossing defects to hypertensive retinopathy. As you can see, we can use our own terminology and still retain the power of Code Complete.
Another useful feature of Code Complete is that it suggests the codes to you but does not
require you to use them. It is your decision and your discretion as to which codes that are
suggested that you select or don't select to use. It also eliminates the searching for codes and the forgetting of codes at the completion of an examination.
Enter 'Pachs' Get 'Pachymetry'
One of my favorite ways to use Code Complete is to link any text in the plan
to an ICD9 code or a CPT code. For example, when I put just "pachs" in the plan on the Code Complete screen pachymetry has been coded. Code Complete is triggered to code pachymetry based on the word "pachs" in the plan data. This can be very powerful
Code Complete can obviously reduce coding errors, missed or forgotten codes can be eliminated, and you don't have to review the entire exam to make sure you are coding everything properly. It saves time and makes you more efficient in finishing an examination.
Jay Henry, OD, MS, is a clinical assistant professor as well as primary care extern preceptor for The Ohio State University College of Optometry. He currently practices at Hermann and Henry Eyecare, a group private practice in Pickerington, OH. Contact feedback@visioncareventure.com with comments and/or suggestions for future topics.
