Practice Compliance in Documenting and Billing Gonioscopy and Pachymetry in a Resident Ophthalmology Clinic

Abstract

Purpose : Gonioscopy and pachymetry are billable procedures for those patients with diagnoses that meet medical necessity as indicated. Residents excel in performing these procedures and documenting them where indicated. However, it was noted that residents may often not bill properly for these procedures and often leave the billing to the attending teaching physician. We retrospectively reviewed our documentation and billing practices for these procedures in a resident ophthalmology clinic.

Methods : All patient encounters performed by ophthalmology residents over a 5-month period (January thru May 2021) were retrospectively reviewed for appropriate documentation and billing of gonioscopy and pachymetry. All patient encounters were supervised by teaching physicians in an outpatient ambulatory ophthalmology clinic at the Texas Diabetic Institute, San Antonio, TX. Each electronic medical record (EMR) was reviewed for appropriate documentation and billing. The data was analyzed using R software.

Results : A total of 1,500 patient encounters were reviewed. Gonioscopy was documented in 37 records, but only 14 (38%) of these records were properly billed for. Gonioscopy was billed for in 3 records where the gonioscopy was not properly documented. Pachymetry was documented in 31 records, but only 20 (65%) were properly billed for. No records showed billing of pachymetry without proper documentation. The exclusion of these billing codes was statistically significant (P_gonioscopy = 0.0, P_pachymetry= 0.0). All those records were gonioscopy and pachymetry was documented and/or billed had a diagnosis to support medical necessity for the procedure.

Conclusions : Billing for both gonioscopy and pachymetry were preferentially excluded from recording. This result is likely due to inadequate resident understanding of billing for these procedures. It is ultimately up to the attending physician to review the documentation, attest and cosign the note, and verify the final billing diagnosis and procedure codes. Good practices aim for 100% compliance in both documentation and billing. However, these data emphasize the importance of teaching proper coding and billing practices to residents in training as they prepare to enter independent practice.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.

 

Table. Gonioscopy and Pachymetry Procedures