Ask the AOA Coding Experts: Top Ten QuestionsMydriasis of ophthalmoscopy Always includes...
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Ask the AOA Coding Experts: Top Ten Questions Doug Morrow, O.D. Harvey Richman, O.D. Rebecca Wartman, O.D.
Transcript of Ask the AOA Coding Experts: Top Ten QuestionsMydriasis of ophthalmoscopy Always includes...
Ask the AOA Coding Experts: Top Ten Questions
Doug Morrow, O.D. Harvey Richman, O.D.
Rebecca Wartman, O.D.
1.All information was current at time it was prepared
2.Drawn from national policies, with links included in the presentation for your use
3.Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations
4.Prepared and presented carefully to ensure the information is accurate, current and relevant
5.No conflicts of interest exist for the presenter- financial or otherwise
Disclaimers for Presentation
Disclaimers for Presentation
6. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services
7. AOA, AOA-TPC, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein
AOA Third Party Center Coding Experts
Rebecca Wartman OD Douglas Morrow OD Harvey Richman OD
Coding Basics- Don’t Fall Asleep
CPT Procedure Codes What You Do
ICD-9-CM/ICD-10-CM Diagnosis Codes What You Find
HCPCS Codes What You Supplied or Do
Modifiers What’s Different
Coding Systems
Identifies physician services and procedures
Copyright held by the American Medical Association
Updated yearly through CPT Editorial Process
Changes effective January 1 every year
CPT Procedure Codes
I just bought an OCT.
The company installed and taught us how to use it but they didn’t teach us how to interpret it.
Can you teach us?
Question 1A Interpretation of Testing
NO! We cannot teach you how to interpret your OCT findings
BUT We can give you coding guidelines for OCT use
AND
Resources to learn how to interpret findings: Lectures
Websites
Manufacturer materials
Experience
Question 1A Interpretation of Testing
I was told by one of my friends that I should only use intermediate level codes for routine eye exams but I dilate all my patients.
Doesn’t that make them comprehensive exams?
Question 1 Dilation
Not necessarily!
General Ophthalmic Services Codes
New Patient vs. Established
Comprehensive vs. Intermediate
Elements of services
Guidance on coding
Question 1 Dilation
General Ophthalmologic Services
CPT ® Codes Note: Current Procedural Terminology(© American Medical Association) is the only accepted source of definitions for these services. 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient 92004 ;comprehensive, new patient, 1 or more visits
General Ophthalmologic Services
CPT ® Codes
92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient 92014 ;comprehensive, established patient, 1 or more visits
General Ophthalmologic Services
Comprehensive Ophthalmological Services 92004 & 92014 Introduction in CPT ® General evaluation of the complete visual system (1 or more sessions) Includes: • History • General medical observation • External examination • Ophthalmoscopic examination • Gross visual fields • Basic sensorimotor examination Often includes: • Biomicroscopy • Examination with cycloplegia or mydriasis • Tonometry. Always includes: Initiation/continuation of diagnostic and treatment programs
General Ophthalmologic Services
Intermediate Ophthalmological Services 92002 and 92012
Introduction in CPT®
Evaluation of new/existing condition complicated by new diagnostic/management problem not necessarily related to primary diagnosis
Includes
History
General medical observation
External examination
Adnexal examination
May Include
Other diagnostic procedures
Mydriasis of ophthalmoscopy
Always includes
Initiation/continuation of diagnostic and treatment programs
Diagnostic and Treatment Program
Includes, but not complete list: • Prescription of medication • Special ophthalmological diagnostic or treatment
services Consultations • Laboratory procedures • Radiological services
General Ophthalmologic Services
How Differ from E&M
Intermediate & Comprehensive
Ophthalmological Services:
Medical decision making cannot be separated from examining techniques Itemization of service components is not applicable
• Slit lamp examination • Keratometry • Routine ophthalmoscopy • Retinoscopy • Tonometry • Motor evaluation
General Ophthalmologic Services
Some Medicare Carriers further define what constitutes Intermediate and Comprehensive Ophthalmic Examinations Source appears to be CPT Assistant Article August 1998 and the CPT introduction and definitions This review helps in determining intermediate vs comprehensive service levels
Intermediate
COMPREHENSIVE
General Ophthalmologic Services
Ten Elements of Ophthalmologic Examination
• Confrontation fields • Eyelids/adnexa • Ocular motility • Pupils/iris • Cornea • Anterior Chamber • Lens • Intraocular pressure • Retina (vitreous, macula, periphery, and vessels) • Optic disc (Should be 12 elements including acuity and bulbar and palpebral conjunctiva but not always listed)
General Ophthalmologic Services
Comprehensive examination eight or more elements including:
Fundus examination with dilation** Motor evaluation **Note that CPT definitions do NOT require dilation but some carriers do- some with further statement “with dilation unless contraindicated”
General Ophthalmologic Services
Intermediate Examination
Seven or fewer elements
AND Additional Ophthalmic Tests
General Ophthalmologic Services
Since insurance is not covering, my patients are getting mad about my refraction and contact lens exam fees.
Is there a way that I can incorporate them into my eye exam fee?
Question 2 Refraction
Refraction and HIPAA
Contact Lens Codes
Inducement Violations
S-Codes
Presentation of fees to patient
Question 2 Refraction
General Ophthalmologic Services
Special Ophthalmological Services
92015 to 92140 Reported in addition to general ophthalmological services or E&M services Interpretation and report by the physician or QHP is integral part of special ophthalmological services where indicated
Determination of refractive state
Statutorily not covered by Medicare
RVU $20.42
Consider Modifiers
Refraction-92015
General Ophthalmologic Services
Coding Guidelines Refraction not covered by Medicare
May file for denial GY modifier may be necessary
• indicates that the service is statutorily excluded from Medicare coverage
Advanced Beneficiary Notice (ABN)
S0620 – routine ophthalmologic examination including refraction, new patient
S0621 -- routine ophthalmologic examination including refraction, established patient
S-Codes
S CODES PROBLEMS
No valuation
No further definitions
Insurers free to interpret at will
Routine Examination Codes?
Just because the patient has insurance doesn’t mean that the procedure is covered
Know the plans and how to present to patient
Plan rules not always HIPAA Compliant
Fee Presentation
I keep getting denials from Medicare for submission of a second eye cataract post op.
What am I doing wrong?
Question 3 Cataract Post op
Modifier Use
Surgical Correct Billing Guidelines
Question 3 Cataract Post Op
Surgeon -54 modifier indicating surgical care only
Post-op period = 90 days
Surgery day = Day 0 Transfer of care
Transfer date
Surgical Procedure
Surgical Diagnosis
Post Op
-55 modifier
-79 modifier
RT modifier
LT modifier
Post Op-Modifiers
Key Points Summary
Thorough documentation is vital
Communication with the surgeon is critical
Surgeon must document the exchange of care
Patient must understand exchange of care process
Patients must have choice for post-operative care
Communication with the patient is critical
ALWAYS act in the best interest of the patient
How do you handle a patient that is covered by a commercial carrier, is under 65 and has cataract surgery and the insurance company tells you they will not pay for co-management?
Do I bill E&M’s for the post op?
Do I fight with the carrier? Or both?
Question 3A Cataract Post Op
Insurance company policies
Options?
Question 3A Cataract Post Op
My camera company told me that since my camera does a better job of looking for retinopathy then I do, that I can I use that instead of dilating my diabetic patients and bill 92250. It makes sense.
Question 4 Fundus Photography
Fundus Photography
Diabetic Eye Exam Requirements
PQRS requirements
Question 4 Fundus Photography
Diabetes and Retinal Examinations
American Diabetes Association and the National Institutes of Health’s positions
retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia
patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the onset of diabetes
Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination soon after diagnosis.
Subsequent examinations for type 1 and type 2 diabetic patients are generally repeated annually
Diabetes and Retinal Examinations
American Diabetes Association and the
National Institutes of Health’s position
Photos are not a substitute for a comprehensive eye
exam
92250 Purpose
CPT® 92250 considered medically necessary to monitor pathology
Reimbursed by Medicare and other third party payers per guidelines for fundus photography
If my patient is not taking any medicine, how do I document PQRS for them?
Question 5 PQRS
PQRS before 2014
Eye Codes
ERx and EHR
PQRS in 2014 and beyond
9 measures
Public health options
Question 5 PQRS
Physician Quality Reporting System PQRS 2014
If you DO NOT report in 2014 you will be penalized in 2016
Your Medicare reimbursement will drop by 2.0%
2017 penalties will be based on 2015 reporting performance
Avoiding 2015 Penalty- May still be possible
If you DID NOT report AT LEAST ONE PQRS measure in 2013, your Medicare reimbursement will drop by 1.5% for 2015
May still be time ONLY IF you have not yet filed all 2013 claims (cannot re-file previously submitted claims to add PQRS measures)
File ONE 2013 CLAIM with PQRS measure to avoid 2015 penalty- before Feb 28, 2014
Satisfactory PQRS Reporting Claims-Based for 2014 PQRS Bonus
For satisfactory reporting:
Must report at least 9 measures from 3 different National Quality Strategy NQS) domains, 50% of time for each measure
This does NOT mean 9 measures on every claim at least 50% of time
Choose 9-10 measures from 3 different domains and use them when appropriate at least 50% of the time
#130 Documentation of Current Medications
in the Medical Record
G8427: List of current medications documented by the provider, including drug name, dosage, frequency and route
OR
G8430: Provider documentation that patient is not eligible for medication assessment
OR
G8428: Current medications (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) with drug name, dosage, frequency and route not documented by the provider, reason not specified
HTN exclusions as the following: “Not Eligible – A patient is not eligible if one or more of the following reason(s) are documented:
Patient has an active diagnosis of hypertension
Patient refuses to participate (either BP measurement or follow-up)
Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated”
G8784: Blood pressure reading not documented, documentation the patient is not eligible
G8951: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible
What if they are hypertensive?
I want to meet Meaningful Use 2, but it is too hard for my staff to enter into the computer.
Can I just check off the boxes because I write it all down correctly on the record?
Question 5A Meaningful Use
Meaningful Use 2 guidance
AOA resources
Meaningful Use audits across the country
Question 5A Meaningful Use
If a patient comes in with a complaint of something flying in his eye and I find a foreign body, how do I bill it?
I heard someone once say you can’t bill an office visit, is that true?
Question 6 Foreign Body
Modifiers
Surgical Correct Billing Guidelines
New Patient vs Established Patient
ICD-10-CM rules
Question 6 Foreign Body
Foreign Body Removal
65205 Conjunctival FB Removal, superficial
65210 Conjunctival FB Removal, embedded
65220 Corneal FB Removal w/o Slit Lamp
65222 Corneal FB Removal w/ Slit Lamp
Foreign Body Removal
ICD-9 diagnosis codes 930.1 Conjunctival Foreign Body
930.0 Corneal Foreign Body Procedure billed stand alone
Procedure billed with E&M code
Multiple Foreign Body Removal
Same code for one or multiple foreign bodies
-51 modifier (multiple procedures)
-50 modifier (bilateral procedures)
Other Corneal Procedures
65430 Scraping of cornea, diagnostic
65435 Removal of corneal epithelium
Supporting ICD-9 Codes
Scrape and Culture Cornea
370.00 Corneal Ulcer
Debridement of Cornea
371.42 Recurrent Erosion
054.43 Herpes Simplex Keratitis
371.50 Corneal Dystrophy, unspecified
Billing Surgical Codes
Surgical codes are “stand alone” codes
Not usually billed with E&M codes
-25 modifier if E&M visit results in decision for surgical procedure
My glaucoma patient can only come in once per year because their daughter visits only in the summer. I need to do ophthalmoscopy, fundus photos, gonioscopy, pachymetry, fields and OCT on that day or else she will never get it done. I was told that we can do that.
What should I do?
Question 7 Multiple Procedures
Multiple Procedure Payment Reduction
Modifiers
Medical Necessity
Local Coverage Determination (LCD) for Services That Are and Are Not Reasonable and Necessary
Patient education
Question 7 Multiple Procedures
20% reduction to practice expense component for 2+ service(s) furnished by a physician or group practice in an office setting on same day
Multiple Procedure Payment Reduction Modifications
April 1, 2013, American Taxpayer Relief Act of 2012 applied up to 50% multiple procedure payment reduction modifications (MPPR)
20% reduction to technical component for 2+ diagnostic ophthalmology services furnished to same patient-same physician-same day
50% reduction for 2+ surgical procedures furnished to same patient-same physician-same day
Multiple Procedure Payment Reduction Modifications
Multiple Procedures on Same Day
76510-76513 A and B Scans
76514 Pachymetry
92025 Corneal Topography
92060 Sensorimotor exam
92081-92083 Visual Field exams
92132-92136 Scanning Laser
92228 Remote imagining-retinal
92235-92240 FA
92250 Fundus photos
92265-92275 Oculoelectromyography
92283 Color vision
92284 Dark adaptation
92285 External photos
92286 Spectular Microscopy
I finally had a patient with keratoconus that the insurance company paid for the visit with the new code.
The problem was that the carrier did not pay for the contact and said it is not the patient’s responsibility.
What can I do?
Question 8 Keratoconus Contact Lenses
92072
92071
HCPCS code options
Private coverage options
Medicare options-DMERC
Question 8 Keratoconus Contact Lenses
92072
CPT® Fitting of a contact lens for management of keratoconus, initial fitting.
For subsequent fittings, please use either the 9921X or 9201X codes.
Report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code.
The follow up for the contact lens fitting would be billed with E&M codes.
Once the initial contact lens fitting is complete, 92072 cannot be used again after this initial fitting. If the keratoconus patient needed to be treated (fit) again the fitting 92072 would not be used, but instead use an E&M code and 92310 for the fitting.
92072
92071
CPT® Fitting of a contact lens for treatment of ocular surface disease
Report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code.
This is the appropriate code to use for fitting a bandage contact lens.
The 92071 code would be used when a patient has a traumatic injury (abrasion) or another corneal disorder such as a recurrent corneal erosion, filamentary keratitis or bullous keratopathy. The patient or payer would be billed for the appropriate office visit code, either a 92000 or 99000 code and the 92071 code for the treatment with the bandage contact lens.
92071
The provider may also use a bandage contact lens after the removal of a corneal foreign body (65222). In this case the 92071 code can be billed as a bandage, but some payers will deny the 92071 because the 65222 is valued with a wound dressing included in the payment for the foreign body removal.
92071
I keep seeing these webinars and articles about ICD-10-CM.
If I only see regular patients, do I need to worry about this?
Question 9 ICD-10-CM Revisited
Federal Law
AOA Eye-learn
Vision Plans and coding
EHR Vendors
CMS website
CDC ICD-10-CM website
Question 9 ICD-10-CM Revisited
Why change ICD-9-CM ICD-10-CM?
ICD-9-CM is 30 years old
•Produces limited data about medical conditions
•Uses outdated terms
•Is inconsistent with current medical practice
•Structure limits number of new codes
•Many ICD-9 categories are full
ICD-10-CM everywhere since 1994 (except the US and Italy)
Published by World Health Organization (WHO) US Version maintained by Centers for Disease Control (CDC)
ICD-10-CM Improvements
Harmonizes with other classifications
Removes relationships with procedure codes
Revises diabetes codes - consistent with ADA
Information on diseases and conditions and causes grouped as follows:
• Communicable diseases
• General diseases that affect the whole body
• Local diseases arranged by site
• Developmental diseases
• Injuries
• External causes
ICD-10-CM Resources
American Optometric Association
www.aoa.org/coding
CDC ICD-10-CM Official USA site
http://www.cdc.gov/nchs/icd/icd10cm.htm
2014 release of ICD-10-CM at bottom of page has all the downloads
ICD-10-CM Guidelines [PDF - 512 KB]
ICD-10-CM PDF Format
ICD-10-CM List of codes and Descriptions (updated 7/3/2013)
CMS ICD-10-CM information
https://www.cms.gov/Medicare/Coding/ICD10/index.html
X World Health X but Use for general training only
http://apps.who.int/classifications/apps/icd/icd10training
My doctor went to a lecture recently and told us we can be charging patients for photography of the cornea for our dry eye patients.
When we do, the insurance company keeps denying.
Can you help?
Question 10 Non Covered Procedures
Anterior Segment imaging –spectral microscopy
92286
External Ocular Photography
92285
Medical Necessity
LCD vs. CPB
Glaucoma Suspect
Macular Drusen
Question 10 Non Covered Procedures
A service that appears to meet the technical requirements for coverage may be excluded if that service:
not generally accepted as safe and effective
not supported in peer-reviewed medical literature
not medically necessary in a specific case, or for a specific medical diagnosis
furnished at a level, duration, dosage or frequency not appropriate for a specific patient or clinical condition
Medical Necessity
not furnished in manner consistent with standards of care
not furnished in appropriate medical setting (place of service)
furnished in manner primarily for patient/provider convenience
device not approved by FDA or not included in an FDA trial
test or service considered obsolete by the medical community, and replaced by more efficacious services
Medical Necessity
Resources
Medicare Carrier
CMS
CCI edits
Private carrier guidance
Ask the Coding Experts
AOA Coding Today
State Association Third Party Center
Just because you get paid doesn’t make it right
Any last questions?
All you coding issues are solved! Right!
RIGHT?????
Finally
THANK YOU
