Coding and Billing

Coding and Billing Key: Quality Record Keeping

By Charles B. Brownlow, OD

Consistent, quality record keeping streamlines your billing and coding process–and improves revenue flow. Here are practical steps to improve your process.

The rules for keeping good medical records have evolved over the past couple of decades, essentially reflecting the evolution of rules related to the delivery of good health care. There is some evidence that the didactic and clinical instruction related to medical record in health care education programs, including optometry, have not kept pace. There can be no doubt that today’s optometrists are very well prepared to provide the care, but, sadly, not so well prepared to keep appropriate records of that care or to accurately choose codes to represent the care they provide.

Coding and Billing Toolbox

The American Optometric Association offers resources to help you increase the efficiency of your coding and billing process.

The following medical records and coding resources are available through AOAExcel.

•    Medical records and coding webinars are provided as a no-cost AOA Member-Only benefit to educate doctors and staff on medical record keeping and coding.

• is an AOA Member-Only benefit available to AOA members at no cost (previously $349). is a web-based resource for information related to procedure and diagnosis codes, national and local coverage rules and Medicare relative value information.

•   Codes for Optometry, is available in print and searchable CD formats from the AOA Order Department. This two-volume set includes Current Procedural Terminology from the American Medical Association, and a separate volume of diagnosis codes used in eyecare, Medicare’s Correct Coding Initiative, the HCPCS codes for reporting materials in Medicare, and the Documentation Guidelines for the Evaluation and Management Services.

•    Coming in 2013: An EHR & Medical Records Compliance Program.

Visit for integrated professional resources to improve patient quality of care, operational practice excellence and informed business decision-making.

For more information:

Record Keeping Fundamentals the Same Regardless of Technology

The basics of good record keeping are the same for paper medical record forms or electronic health records. Since electronic records were created with the input of practicing doctors, some of the “convenient” features of EHR are potentially counter to medical records standards. Also, the convenience can lead one to rely upon the expertise of the EHR developers without ever learning the components of or the rules associated with good medical record keeping. Indeed, it may become painfully clear during an audit by Medicare or another insurer that the software is not consistent with medical records principles or is providing “convenience” at the expense of accuracy and/or compliance.

Whether we are discussing patient care or record keeping, there is no substitute for knowledge gained through study, training and experience. Medicare and other insurers are not interested as to why your medical records are not compliant…they require that they are. It’s up to each doctor to ensure that she or he is compliant and, if not, to do what is necessary to become compliant.

Invest in Valuable Record Keeping References

Consider two excellent, inexpensive references that every health care provider must own or at least have access to. First, Current Procedural Terminology (CPT American Medical Association), is available for approximately $85 from the AOA Order Department, 800-262-2210. Second, The Documentation Guidelines for the Evaluation and Management Services, 1997, available for free download at  AOA and AOSA members also have free access to the CPT definitions and the Documentation Guidelines by simply registering with

At very least, every practicing optometrist should be familiar with the Introduction section for office visits, found at the beginning of each of these references. They provide excellent reminders; amid all the conflicting instructions you may be hearing from insurers, magazine articles, webinars, etc.; of the true purpose of the medical record and its role in providing excellent patient care.

The medical record’s main purpose is to facilitate patient care. The medical record’s role in claims submission or payment issues must be considered to be secondary or even tertiary. Our first job as health care providers is to take care of the needs of each patient–the patient record must be focused on the same goal. The Introduction from the 1997 Documentation Guidelines assists us in keeping good records and in choosing codes accurately, but, most importantly, the Guidelines provide a framework for good records. Indeed, they were created to reflect the basics of medical record keeping established in clinical practice over the past three or four decades. Consider the following quote from the introductory section of the 1997 Documentation Guidelines:

What is Documentation and Why is It Important?
Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:
•    The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time.
•    Communication and continuity of care among physicians and other health care professionals involved in the patient’s care.
•    Accurate and timely claims review and payment.
•    Appropriate utilization review and quality of care evaluations.
•    Collection of data that may be useful for research and education.
An appropriately documented medical record can reduce many of the “hassles” associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

General Principles of Medical Records Documentation
The principles of documentation listed below are applicable to all types of medical and surgical services in all settings.
1.    The medical record should be complete and legible
2.    The documentation of each patient encounter should include:
•    Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
•    Assessment, clinical impression or diagnosis
•    Plan for care; and
•    Date and legible identity of the observer
3.    If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
4.    Past and present diagnoses should be accessible to the treating and/or consulting physician
5.    Appropriate health risk factors should be identified
6.    The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
7.    The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

Hopefully, this little snippet of information from the Documentation Guidelines will encourage you to do a little more research and study regarding good medical record keeping. The Guidelines go on to provide keys for accurate coding of your medical records. It’s amazing, but the Documentation Guidelines, the main rules for choosing office visit codes correctly, reside in just twelve pages. They will provide you a very quick and nearly painless assist as you develop your internal program for medical records compliance, while also providing you the support you’ll need if and when your patient records are audited by Medicare or another insurer.
Questions:  Feel free to contact me at

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Treating Ocular Trauma: Do You Know How to Code for It?

Charles B. Brownlow, OD, is an eyecare consultant and AOAExcel Medical Records and Coding Consultant. To contact him:

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