Episode Transcript
Speaker 0 00:00:00 Welcome to the Dry Eye Coach podcast series. Click on dry eye. Your insider passed to the most exclusive dry eye topic. The series will raise awareness about the current and future state of ocular surface disease. The podcast will focus on a variety of topics.
Speaker 1 00:00:15 In today's episode, we have the pleasure of speaking with our good friend Jason Miller, who is a partner in a for doctor private practice in Powell, Ohio. I've worked with Jason for over the last decade, both lecturing and writing on this topic of billing and coding. And we both worked together on AOA as the coding experts, and he also serves on the coding committee previously before I joined the coding committee. So thank you all.
Speaker 2 00:00:39 Appreciate Tracy. Thank you guys for having me. It's a pleasure to be here with you guys.
Speaker 1 00:00:44 Hey, tell us a little bit about your practice before we get into the nuts and bolts of our topic.
Speaker 2 00:00:48 Yeah, so sure. I've been very fortunate. Uh, you know, I opened, uh, or I opened, I joined a practice, uh, when I graduated, uh, you know, just a few years ago. And I was fortunate to, uh, be in a growing community and we've, um, been blessed to have some great patients and we've grown from, you know, being a pretty small location, one doctor location to four doctor, pretty, pretty large practice. And we, we, you know, very multispecialty practice. We, we provide just about everything we can, and we love to, we love to continue to expand what we, what we can provide our patients and provide the best quick care, you know, that we know of. I, my, my, my, um, my, uh, my big two areas that I love to work with are not only just contact lens care, we do a lot of research and contacts.
Speaker 2 00:01:37 Um, I also do a fair amount of research in dry eyes as well, in dry eyes. And ocular surface disease are a big staple of what we provide in our practice. And obviously we, you know, we, you know, we wanna provide everything to our patients, but I've learned pretty early on, I, I didn't wanna be just, uh, in our practice, we didn't want this to be just a, a one thing that we provide. We wanted to be, um, we wanted to diversify what we offer our patients so that we can make sure that, um, we can provide what they need to suit their needs and continue to grow in the right fashion. So that's kind of how we've developed our practice and how I've developed myself as an optometrist through the years.
Speaker 3 00:02:15 So how did you get involved in billing and coding? Was it just as a natural extension through what you're doing at your practice? Or did you have a specific interest in the business aspect?
Speaker 2 00:02:24 Oh my gosh, yes. Um, I've, I've always had an interest in the business aspect of optometry. I, I think, um, early on, um, I've learned just from some of the different practices I've worked in that there's some amazing doctors out there that may not understand kind of the nuts and bolts of how to run their practice and maybe even leaving lots of revenue on the table. Um, so yeah, I, I, early on I wanted to go back and finish my MBA and, and understand more about the business and understand how not only can I just run the practice better, but also understand what I'm doing and, and why I'm doing that. And, um, you know, I think billing and coding is a natural, is a natural, you know, outcropping of that. We want to be able to, um, understand that we're not gonna be leaving anything on the table with, um, with what we're providing.
Speaker 2 00:03:13 It's not, it's not trying to maximize our billing. It's trying to, um, to be able to get paid for what we're appropriately deserve to get paid. We're providing high quality care, we're providing high quality service to our patients. And, and to, to do that. And then to do that at a discount is, you know, you don't wanna do that as a, as a slap in the face. You wanna be able to provide the quality care that you wanna provide and feel the freedom that you're gonna get reimbursed appropriately for that time and expertise that you've, you've provided to your patients.
Speaker 1 00:03:43 Hey, Jason, what are some of your go-to resources when it comes to billing and coding? Because we know we all have our experience, but it doesn't mean we're doing it, right? So what are some of the resources you recommend?
Speaker 2 00:03:53 Yeah, you know, I think, um, AOA coding is, has some great resources. Um, you know, I've, I've used those through the years as my, as probably my go-to resources there. Um, some of their, um, you know, their AOA coding books that they provide early on, now most everything's electronic. Um, I also think it's important to get to know the right people. I was fortunate to work with you all through the years, and fortunately to work with Chuck Brownlow through the years and, and get to know people that you respect and you respect their opinions on, on, on how they're doing things. And, and it's, it's not specifically about, you know, upcharging or, or anything. It's about, uh, charging appropriately for your time and your expertise and, and being fair to, to not only yourself, but your patience. So, yeah, I think, um, you know, I think I would, I would point to AOA coding as my, as my, you know, go to online resource I'd go to.
Speaker 2 00:04:47 But I would also say getting to know the right people and, and who those resources you can go to if you, And it's nice just to bounce ideas off people. And you know, I think that, um, you know, there's no one has all the answers and I think the, uh, I think the codes are written to be a little vague at times and to be up for interpretation. So it's nice to know how other people are interpreting some of the rules that are out there. And, um, and so yeah, I think, I think that's probably the biggest resources I've gone to over the years.
Speaker 1 00:05:17 But just to be clear, just cause you get paid does not mean you did it, right?
Speaker 2 00:05:21 Yes. That's a hundred percent correct. Yeah. So, so getting paid is not right cause we've all been audited through the years and if you, if you've been audited, it's about being able to, is about being able to understand why you build something that way. And, um, and so if you don't know the rules and an auditor comes in and asks you like, Why did you build this, this level? And you say, I don't, I don't know, I, I thought this was what you're supposed to do with all these patients. Um, that's not the right answer.
Speaker 1 00:05:46 Well, Tracy and I have a lot of coding questions for you, but limited amount of time and so I'll let you go first. Tracy
Speaker 2 00:05:54 <laugh>.
Speaker 3 00:05:54 Okay. This is great cuz now I know a person, so congratulations on now being one of my people.
Speaker 2 00:05:59 <laugh>,
Speaker 3 00:06:00 We often get these, um, questions on how to address the vision versus medical issue. What are some purposes in your practice that you use to educate patients on the need to switch, um, from the vision to the medical prior to dry visits?
Speaker 2 00:06:14 Yeah, it's such a great question because I think it's something that optometry has, has, um, you know, probably over the years not done a very good job of is just understanding, you know, hey, how am I gonna provide dry eye care at the reimbursement that I'm, rate that I'm getting from a vision plan? Right? And, and, and, um, yeah, I mean I think it really comes down to what is what, what's that patient for, what's their reason for the visit, what did you determine? Is there issues that are because of that reason for the visit? And that's gonna lead you to, um, the choosing the right plan for that. There are times also where you can coordinate those benefits, right? So you may want to, there could be times where a patient comes in and, and um, you know, they, uh, they not only, you're not only doing a follow up on their, on their, on their, on their ocular surface disease and you're not doing a follow up on what their treatment is.
Speaker 2 00:07:05 Um, but now they wanna do their vision exam at that same time. There's times where you can send that to their medical. And then once that, once that, once that explanation of benefits for the E O B comes back, you can balance build that to their vision and, and oftentimes the patient is, is taken care of on both sides. So in all the vision plans, they give you a way of how to coordinate those benefits. They try to make it maybe not so easy at times, but they do give you that option to, uh, to, um, coordinate the benefits. So it doesn't mean you can't build both at the same time. You have to build a medical first and then you take that EOB and you send it to the vision plan secondary and they, uh, and they will pay you accordingly based on what, what that plan provides.
Speaker 1 00:07:45 Hey, did I just hear you? I'm supposed to read those contracts.
Speaker 2 00:07:49 You should
Speaker 2 00:07:50 Probably look it over a little bit. You know, you may able to know a little bit of, of, of, of what's going on with those contracts, but, uh, but yes, not, not, you know, word for word, but uh, but there are some good knowledge in there and, and, and at the end of the day, I can tell you I don't read those contracts either. Um, it's, uh, you know, some of it is understanding, um, from the resources that that, uh, we get from, um, from, from each other as, as billing, um, people, or not only experts, just billing people that understand the system. Um, but also understanding, um, you know, what, um, what we're being told from, from the plans.
Speaker 1 00:08:25 Uh, you explained already about if patient comes for vision, they have dry eye, you know, reappoint them with for their medical exam. And then you said the opposite as well. They're there for medical but they want glasses. What are some pearls or tips that you can share in regards to your, your staff? Cause they're the ones talking to the patient. Is there anything that they do on the front end before you even get to you to, to help the patient understand there's two different insurances we may need to use both.
Speaker 2 00:08:54 Yeah, you know, I think it starts at the front desk when they check in and, you know, they, they may think, Oh, I just, they just need my VS p or I just need my imed or whatever my vision plan is. Um, and then our staff, the first thing they ask is, we, you know, do you have a copy of your medical insurance card? And, and there are definitely patients that are like, Well, why do you need my medical insurance? Well, we treat medical issues all the time here, so there are times if you've got a medical issue, we need to know what your medical plan is if we need to, um, if we see that they've got something going on on their ocular surface or even something going on, you know, could we have a vire detachment or something else that's going on that we need to follow, um, or cataracts, right?
Speaker 2 00:09:34 Those types of things. You know, it's important to understand that medical insurance that, uh, so that starts with the front desk. They are gathering that information when, when a patient checks in, uh, and then also goes, follows through with our technicians. They do a very thorough, um, you know, basically reason for visit kind of history, uh, with the patient in the exam room. And so understanding that this patient, when we, we walk into the room, I know what their vision is. I, I've got some pretest information, um, I've got, uh, some of their chief complaint or their reason for vision that they're there, and then I can expand on that and, and try to try to get to the heart of what their reason is there. So I think, um, you know, we, we do have some patients that, um, will sometimes ask, Well, which one's gonna get built today?
Speaker 2 00:10:20 Well, we don't know that ahead of time. You know, we need to find out what you're here for. And, uh, but we do have, we do have a brochure that we can hand out that talks about the differences. Um, I, you know, I think we've been doing this long enough in our practice. We don't utilize that quite as much. Um, but I think initially, you know, when we started implementing this type of system that the, that we, we did have a brochure that talks about what's the differences for, for the medical versus the vision because there is a lot of confusion from the patient care side. They, um, they don't understand, um, well, why do you need this one for that one? And, and so yeah, we, we, we do a lot of education for the staff, so they're very familiar with how to talk to patients about the differences.
Speaker 1 00:10:58 Tracy, how do you all handle it? I mean, I'm in a medical practice, I don't have any vision here clients, but any pearls from your end?
Speaker 3 00:11:04 Well, um, I'm a referral only based service. So if we, if if dry is detected in one of the other doctors services and they want to refer that patient over to see me, they're sent to a very specific person who gives them a call back to schedule, explains in great detail. We call her my dry concierge. So she really sets up the expectations. This is why my conversion rates are through the roof, because the patients know exactly what's about to happen to them cost-wise and insurance wise before they hit the door. So if somebody's not able to do it or is not interested from that price point perspective, they don't tend to book with me. So, um, it, it happens that we're educated very well on what, what patients can do, which does bring me to your point, like what do you do about patients, um, who need to do the cash paying services? Cause as, you know, not all dry therapy covered by insurance.
Speaker 2 00:11:54 Yeah, no, I I, um, I you brought up something I think I just wanted to, wanted to hit on as I love that you, the one thing that we don't wanna do is surprise a patient when they're checking out. And I think that's really important that we are upfront with our fees and our services, um, because, um, you know, we're not gonna be able to continue to grow and, and have patient retention if they get to the, to the checkout at the end, and they're like, and they're surprised with the bill. So I think it's really critical that we, um, that we do set those expectations appropriately ahead of time. So you do need somebody talking to, to the, to your patients about, um, about, uh, you know, what insurance or is this cash pay this or that. Um, so any of the cash pay services that we provide, um, and we do offer quite a few of the, um, it is important that, um, we do talk to them ahead of time with that.
Speaker 2 00:12:40 We have a form that we go over. It gives them exact pricing, what's included in that. Um, and you know, it's a very soft sale. Honestly, I talk to the patients about the advantages of this treatment, this advanced treatment is gonna provide, you know, this, and this is why I'm recommending this to you, and I do think that's important, is that a patient understands the why. If they don't understand the why, they're not gonna understand why they're paying, you know, extra X dollars for something. So, so yeah, I think that, um, you know, we have, we have our, our our templates, we have our forms, we have our, um, our, uh, our, uh, our staff understands their, um, their wordage that they're gonna use with patients whenever it comes to talking about these treatment options. And so I think it really makes, um, that process pretty seamless. We really don't have too much of an issue, you know, as you said, I mean, you've got a concierge, I love that word, um, you know, talking to, talking to your patients ahead of time about what the appropriate expected fees are gonna be. And, and I think that's, that makes all the difference in the world. Just there's no surprises when they check out
Speaker 3 00:13:44 Mm-hmm. <affirmative>, there's something you can do for everybody, but it's just making sure that they know what's gonna be at their expectations are super important. You wanna set those appropriately,
Speaker 2 00:13:54 <laugh>. Yeah. You know, and, and, and we have a, like, you know, a dry kit per se that we will, that we'll give out, not give out, we sell at a pretty reasonable rate at, at the initial appointment, even if it's not a dry workup or maybe if they're just in for the exam, but then I'll have them back for that dry eye workup. So it's just something that, that we, um, you know, in that kit, you know, have, you know, a variety of things, whether it's nutraceuticals or, or heat mask or, uh, you know, it could be, it could be a HypoChlor spray or something like that, right? Putting those things in a little kit that you get a patient started with and then have them back for more thorough evaluation, I think it signifies to them, you know, I just don't need to go grab something over the counter because that's what they're gonna do. They're gonna grab a series of drops and none of them are gonna work. So it's, so it's important that we that, and if you are gonna prescribe something over the counter, it's important that you dictate what that is so they're not just, you know, just a grab bag approach to that.
Speaker 1 00:14:49 So Jason, um, so a patient comes in, we know that some insurances cover some tests like MMP nine and some don't. Do you have your patient sign an ABN for all those, or you know, if it's private pain, you know, the private insurance isn't gonna pay for it. Do you just not do the test? Or what are your thoughts on all that?
Speaker 2 00:15:09 Yeah, so, you
Speaker 1 00:15:10 Know, the not exclusion of medical benefits, Medicare,
Speaker 2 00:15:15 Yeah, I think the ABN is a great idea. I think it's, it's a form that you can have in your office. I can't say that we get that form a hundred percent of the time on the staff. We certainly try and educate them and I, um, but I think it's really important that, you know, that that is, it is a, some sort of form. And the ABN is really nice because it is, what is recommended on the coding and billing side is to have them sign an ABN form. Um, Medicare specifically, I, um, some of these patients aren't Medicare, so, you know, an ABN form doesn't, you know, it's not, um, quite as critical, but I think it's really, it's really useful as a tool that each of us can use within our practices to, uh, to educate the patient on what their expected fees are and why it's outside of their, of their normal coverage amount.
Speaker 1 00:15:59 Mm-hmm. Yeah. And, you know, cause this is information that we're gonna want from the patient. And so whether it's Medicare or private insurance, they have their own form as well that you could use. I mean, they say, Hey, if they're not paying for it, tell the patient this is the information we need. So, yeah. Uh, one of my last questions for you and Tracy may have others is, so with ICD 10 changing, you know, the last year in 2021 and, you know, schedule three, schedule four, what things are you noticing? Because, you know, you see part of that we're looking at how many problems they have, is the acute or chronic, how many, you know, what tests we're looking at, but then also treatment, but for treatment for dry eye, if you done prescription therapy, that already ranks it a little bit higher. I mean, do you have any comments on ENM or pointers for that?
Speaker 2 00:16:46 Yeah, you know, I, yeah, so
Speaker 1 00:16:49 I gave you a minute and 30 seconds to answer
Speaker 2 00:16:52 This one <laugh>. That's a, that's a tough one here at the end of the, Wow. Wow. Thanks Wal. I appreciate that <laugh>. Um, so, um, no, I would say there's definitely been a lot of confusion with the changes on the new ICD 10, but, but you're right. At the end of the day, if you're prescribing, if you're prescribing your patients something, um, a prescription job, you know, you're definitely gonna be hitting one of the higher level codes in general. Um, but at the end of the day, it is important to understand, um, what level nine, nine series code you're gonna be hitting based on what service level you're providing and how many issues they have going on. Um, yeah, I, I think, you know, I try not to think too much about that while I'm doing an encount. I really don't want that to be in the back of my mind.
Speaker 2 00:17:34 I'm not trying to do extra tests just to, just to get to a higher level of billing. Um, but I think it's, you know, the patient's problems are gonna dictate what tests and what things you need. And they, you're gonna, if you're providing a higher level service and you're prescribing drops, you're usually gonna hit one of the higher, higher level codes. You level four for established patient or level three for a new patient most of the time. And, you know, at the end of the day, if you're providing that care, you deserve to bill for that appropriate level care too. So it is important to understand what, what, what, uh, what those rules are.
Speaker 1 00:18:03 Hey, well you did a great job answering that in a short amount of time. Uh, but just be clear for our listeners, what we're talking about is the level of medical decision making. You know, it comes in three different, three different boxes. One is the number and complexity of problems addressed. A second area is gonna be amount and complexity of the data to be reviewed. And the last thing that Jason and I both mentioned is when you're prescribing treatments, the risk of complications, morbidity, or mortality of patient management. So that's where we're coming from. Uh, there are many great resources. Jason mentioned aoa uh, coding today. If you go there, there's excellent webinars that can talk to you how to determine which codes they are. And they weren't like before, just cause, you know, I had a technician say, Oh, that was a level four cause they were dilated today. I said, Nuh, that's not how it works anymore. So, no, and it didn't really work back then either. So any final pearls that you have for us, Jason, in regards to this whole, uh, billing and coating for dry eye?
Speaker 2 00:19:00 Yeah, no, I, my, my final thing would just say if you, if you haven't, uh, jumped into dry eye treatment, there's a very low level of, of entry into that, into that, you know, into that realm. So it doesn't take a whole lot of investment for you to be able to provide high quality dry eye care within your practice. And, you know, you need, you need some fluorescein strips, some listening green strips. You know, I think there are some excellent, excellent advanced, advanced, um, instrumentation out there. If you wanna look at, you know, the tear film, you wanna look at the, my meibomian glands. You wanna look at any types of things. There's some awesome imaging sources out there. You don't have to have all of them out of the gate. And I would just encourage everyone, if you are gonna provide that care, it's not only about understanding what, what you're gonna provide, but also knowing how to get reimbursed for your time and your expertise there.
Speaker 3 00:19:49 Very well said. Thank you so much for sharing your coding and billing pearls with us for ocular surface disease and um, I'm sure I'll be having lots of conversations with you in the future.
