Excellence in Optometric Education

Excellence in Optometric Education Excellence in Optometric Education

John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute

John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute

Understanding Medicare Understanding Medicare Guidelines - 2009Guidelines - 2009

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John A. McGreal Jr., O.D.John A. McGreal Jr., O.D. Missouri Eye Associates 11710 Old Ballas Rd. St. Louis, MO. 63141 314.569.2020 314.569.1596 FAX [email protected]

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2009 Medicare E/M Guidelines2009 Medicare E/M Guidelines Compliance

– How To Document the Medical Record– How To Select an E/M Codes, eye codes, “S” codes– How To Evaluate your Fees– How To Effectively Co-manage Surgical Cases– How To Increase Revenues– How To Survive an Audit– How To Understand HIPPA Privacy Rules– How To Implement a Compliance Plan

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2006 New HCPCS Codes2006 New HCPCS Codes V2788 Presbyopia-correction function of an

intraocular lens– For reporting additional, non-covered charges associated

with the insertion of the presbyopia correcting IOLs– Effective Jan. 1, 2006– Recommend ABN

Multifocal IOLsMultifocal IOLs

“Presbyopia-correcting IOLs allowed by CMS on May 3, 2005– ReSTOR– ReZoom– CrystaLens

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2006 New CPT Codes2006 New CPT Codes Pegaptanib for AMD

– 67028 Intravitreal injection - $196.58– J2503 Macugen - $1054.70

Verteporfrin for AMD– 67221 infusion of photodynamic agent - $301.46– J3396 Visudyn - $1400

Bevacizumab for AMD– 67028 Intravitreal injection - $196.58– J9035 Avastin

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2006 New ICD-9 Codes2006 New ICD-9 Codes Must report with 250.5 362.03 Nonproliferative diabetic retinopathy NOS 362.04 Mild nonproliferative diabetic retinopathy 362.05 Moderate nonproliferative diabetic

retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema

– Must report with ICD code for diabetic retinopathy 362.01 = background diabetic retinopathy 362.02 = proliferative diabetic retinopathy 362.03 – 362.07

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2007 New CPT Codes2007 New CPT Codes

92025 Computerized Corneal Topography, Unilateral or Bilateral, with Interpretation & Report– Fee $28.39

67346 Biopsy of Extraocular Muscle

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2007 New ICD-9 Codes2007 New ICD-9 Codes 377.43 Optic Nerve Hypoplasia 379.60 Inflammation (infection) of post

procedural bleb; unspecified 379.61 Inflammation (infection) of post

procedural bleb; stage 1 379.62 Inflammation (infection) of post

procedural bleb; stage 2 379.63 Inflammation (infection) of post

procedural bleb; stage 3

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2008 New CPT Codes2008 New CPT Codes 68816 Probing of nasolacrimal duct w or w/o irrigation,

with transluminal balloon catheter dilation– Fee $551.79

67041Vitrectomy w removal of ERM 67042 Vitrectomy w removal of ILM for repair of

DME, or macular hole 67043Vitrectomy w removal of CNV 67113Repair of complex RD (PVR, diabetic

traction RD, ROP, tear >90 degrees) w vitrectomy and membrane peeking, includes everything

67229Preterm infant (<37wks gestation, birth to one yr), photocoagulation or cryopexy (ex ROP)

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2008 New ICD-9 Codes2008 New ICD-9 Codes 364.89 Other disorders of the iris and ciliary body

(prolapse, NOS)– Excludes prolapse of iris in recent wound

V49.85 Dual sensory impairment– Blindness with deafness

V68.01 Disability examination– Use additional code to identify specific examination,

screening, and testing performed (V72.0-V82.9) 364.81 Floppy iris syndrome*

– Can’t use for 66982

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2009 New CPT Codes2009 New CPT Codes

0198T Measurement of ocular blood flow by repetitive IOP samples, with

interpretation & report 65756 Keratoplasty, endothelial 65757 Backbench preparation of corneal

endothelial allograft prior to transplantation

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2009 New ICD-9 Codes2009 New ICD-9 Codes 362.2 Retinopathy of prematurity, unspecified 362.22 ROP stage 0 362.23 ROP stage 1 363.24 ROP stage 2 362.25 ROP stage 3 362.26 ROP stage 4 362.27 ROP stage 5 364.82 Plateau iris syndrome 372.34 Pingueculitis

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Job Growth and Tax Relief Reconciliation Job Growth and Tax Relief Reconciliation Act of 2003Act of 2003

Bush signed May 28, 2003 3rd largest tax cut in history Encourages businesses to increase capital spending

– Section 179 expense limit increased to $250,000.00 for equipment put in service by 12.31.08

Purchased can be financed and interest expense is also deductible Applies to leased or pre-owned equipment

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Tax Relief and Health Care Act of 2006Tax Relief and Health Care Act of 2006 Set conversion factor for physician payment at same

level as in 2006– Reverses statutory mandated 10.6% negative update for 6

months– “Deal” provides for

0.5% fee increase Extends expiring incentive payments for rural physicians Extends bonus payments for quality reporting

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Health Insurance Portability and Health Insurance Portability and Accountability Act of 1996Accountability Act of 1996

President Clinton & USAG J. Reno– #2 priority: prosecution of health care fraud– $104 Million: Appropriations to HHS– $70 Million: OIG– $47 Million: FBI fraud investigation unit– Criminal offenses expanded– $10,000 fine / line item violation– suspension of payment and participation from program– Yielded $23 return on every $1 spent in 1997

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Dead Doctors Billing Scams 2000-2007Dead Doctors Billing Scams 2000-2007

478,500 false claims 16,500 dead physicians $92.8 million in payments just by Medicare 16% made by doctors dead for more than 10 years

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Qui Tam RelatersQui Tam Relaters Amendment to False Claims Act of 1986 Encourages private individuals to sue in the

government’s behalf Whistleblowers - 30% of recoveries

– $1 Billion paid since 1987 in Qui Tam actions Compliance Plan

– Eliminates aggressive or conservative billing philosophies– Removes incentives for whistleblowers– Improves collections while reducing audit risks

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Medicare Review Strategies - 2008Medicare Review Strategies - 2008 Error rates at below 7% nationally E/M codes represent 75% of errors (highest for Part B)

– 10-1 overpayment –underpayment– Insufficient documentation and incorrect coding

OB/GYN specialty highest error rate nationally at 35.75%

Diagnostic radiology specialty highest projected dollars paid incorrectly at 48 million

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Top 5 Errors by Profession - 2006Top 5 Errors by Profession - 2006

OB/GYN Neurology Chiropractic

Optometry – 11.6%Optometry – 11.6% Nephrology

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Medicare Review Strategies - 2009Medicare Review Strategies - 2009

E/M established codes Laboratory Hospital E/M, subsequent Consultation codes E/M new codes Electrocardiograms Chiropractic Rituximab Hospital E/M, initial

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Top 10 Procedure Codes – Optometry Top 10 Procedure Codes – Optometry Missouri / Jan-June 2007 / 495 Providers Missouri / Jan-June 2007 / 495 Providers

92014 $1,369,645 99214 $ 634,210 92004 $ 562,906 92012 $ 551,297 99213 $ 541,616 66984 $ 395,125 92250 $ 339,862 92083 $ 277,708 99203 $ 199,510 92135 $ 195,427

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Code Set Adoption in HIPAACode Set Adoption in HIPAA CPT-4: Current Procedure Terminology CDT: Code on Dental Procedures and Nomenclature ICD-9-CM (Volume 1,2): International Classification of

Diseases (Proposal to implement ICD-10)(Proposal to implement ICD-10) ICD-9-CM (Volume 3): inpatient disease codes NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding

System

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AOA Optometric Practice Profiles 2005AOA Optometric Practice Profiles 2005 VSP – 21% Other vision plans – 8% Medicare – 19.1% (fastest growing share of revenues) Medicare HMOs – 3% Medicaid – 7% HMOs (private sector) – 8% Out of pocket – 35% Respondents - 90% self-employed, 47% solo, 24%

group, 86% male, mean years in practice 24.2 years

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INTRODUCTIONINTRODUCTION CMS = Center for Medicare & Medicaid Services

(formerly HCFA) - announced June 14, 2001– Center for Medicare Management - traditional fee-for-

service programs– Center for Beneficiary Choices - provide beneficiaries with

information on Medicare, MedicareSelect, Medicare+Choice, and Medigap options

– Center for Medicaid and State Operations - focus on Medicaid and state administered services

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INTRODUCTIONINTRODUCTION CMS CPT ICD

– www.icd9coding1.com/flashcode/userRegister.do Medicare Major Medical E/M Coding (99XXX) Eye Coding (92XXX) Special Ophthalmic Codes

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E/M GUIDELINESE/M GUIDELINES New/Established Patient Chief Complaint History of Present Illness Family History Past History Social History

– New additions level of education, sexual history, marital status/living arrangements

Review of Systems Time

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E/M DESCRIPTORSE/M DESCRIPTORS

History * Examination* Medical Decision Making* Counseling Coordination of Care Nature of the Presenting Problem Time

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CATEGORIES OF SERVICECATEGORIES OF SERVICE Office Visits (E/M Codes)

– New 99201-99205– Estab 99211-99215

Office Visits (Eye Codes)– New 92002-92004– Estab 92012-92014

Consultations (E/M Codes)– Office 99241-99245

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E/M Coding - ConsultationE/M Coding - Consultation

Office Consultations– Opinion / Advice– Not Referral

Duration - short Continuity - expect patient back Documentation - required

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E/M Coding - ReferralE/M Coding - Referral Referral

– Treatment or Care Duration - long Continuity - Do not expect patient back Documentation - not required, but courtesy Warning! - carefully consider the language used in the

correspondence to your consulting specialists– avoid the term referral, unless that is what you mean!

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SELECTING AN E/M LEVELSELECTING AN E/M LEVEL

Identify Category of Service Identify Extent of History Taking Identify Extent of Examination Identify Complexity of Medical Decision Making Review E/M Descriptors

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E/M CODING - OFFICE VISITSE/M CODING - OFFICE VISITS

New Patient (3 of 3)– 99201 - PFH / PFE / SDM / 10– 99202 - EFH / DFE / SDM / 20– 99203 - DH / DE / LDM / 30– 99204 - CH / CE / MDM / 45– 99205 - CD /CE / HDM / 60

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E/M Coding - Office VisitsE/M Coding - Office Visits

Established Patient (2 of 3)– 99211 - Minimal / 5– 99212 - PFH / PFE / SDM / 10– 99213 - EFH / EFE / LDM / 15– 99214 - DH / DE / MDM / 25– 99215 - CH / CE / HDM / 40

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DOCUMENTATION OF HISTORYDOCUMENTATION OF HISTORY

Problem Focused History (PFH)– CC / 1-3 HPI

Expanded Problem Focused History (EPF)– CC / 1-3 HPI / Ocular ROS

Detailed History (DH)– CC / 4 HPI / Ocular ROS / ROS-2 / 1 OF 3 PFSH

Comprehensive History (CH)– CC / 4 HPI / Ocular ROS / ROS-10 / 3 OF 3 PFSH (NEW)

OR 2 OF 3 PFSH (ESTAB)

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Eye Examination DocumentationEye Examination Documentation

VA / CVF / Pupils & Iris / Adnexa Bulbar & Palp Conjunctiva EOM SLE: Cornea / Lens /AC IOP / Optic Nerve / Posterior Segment Neurologic: Orientation (Time / Place / Person) Psychiatric: Mood & Affect (Depression /Anxiety

/Agitation)

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DOCUMENTATION OF EXAMINATIONDOCUMENTATION OF EXAMINATION Problem Focused Exam (PFE)

– Limited Exam / l - 5 Elements Expanded Problem Focused Exam (EPF)

– Limited Exam / 6 Elements Detailed Exam (DE)

– Extended Exam / 9 Elements Comprehensive Exam (CE)

– Complete Single System Exam– All Elements

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Medical Decision MakingMedical Decision Making Straightforward (SF)

– # Dx / Rx Options - Min / Data - Min / Risk - Min Low Complexity (LC)

– # Dx / Rx Options - Lim / Data - Lim / Risk - Low Moderate Complexity (MC)

– # Dx / Rx Options - Mult / Data - Mod / Risk -Mod High Complexity (HC)

– # Dx / Rx Options - Ext / Data - Ext / Risk - High

Comprehensive Ophthalmological Service Comprehensive Ophthalmological Service 92004 / 9201492004 / 92014

Complete system evaluation, 8 or more elements Need not be performed at one session Integrated services where med decision making cannot

be separated from examination methods Includes history, medical observation, external &

ophthalmoscopic, gross visual fields, sensorimotor, biomicroscopy, consultations, dilation (cycloplegia), mydriasis, tonometry, initiation of diagnosis and treatment programs, prescription of medication

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Comprehensive Ophthalmological Comprehensive Ophthalmological ServiceService

92004/9201492004/92014 Always includes initiation of diagnosis and treatment

programs– includes the prescription of medication, and arranging for

special ophthalmological diagnostic / treatment services, consultations, laboratory procedures and radiological services

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Intermediate Ophthalmological Intermediate Ophthalmological ServiceService

92002 / 9201292002 / 92012

Evaluation of new / existing condition, complicated with a new diagnostic or management problem

Integrated services where med decision making cannot be separated from examination methods

Includes history, medical observation, external & adnexal, & other diagnostic procedures, biomicroscopy, mydriasis ophthalmoscopy and tonometry

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Intermediate Ophthalmological Intermediate Ophthalmological ServiceService

92002 / 9201292002 / 92012

Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

7 or less elements

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2004 New HCPCS Codes2004 New HCPCS Codes “S” codes are useful for some private insurers Medicare and other federal payers do not recognize

them They are useful when CPT does not have a code to

accurately describe the service (i.e. LASIK, PTK, PRK, corneal topography) or for invoicing self-pay patients.

They specifically describe “routine exams” including refractions and permit a different charge

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HCPCS “S” CodesHCPCS “S” Codes S0592 Complicated contact lens evaluation S0620 Routine ophthalmologic exam including

refraction; new patient

S0621 Routine ophthalmologic exam including refraction; established patient

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2006 Medicare Fee Schedule2006 Medicare Fee ScheduleOffice VisitsOffice Visits

99201 $34.23- 99211 $19.96- 99202 $60.83- 99212 $35.96- 99203 $90.58- 99213 $49.10- 99204 $128.26- 99214 $77.08- 99205 $163.20- 99215 $112.36-

92002 $66.03- 92012 $60.50- 92004 $120.51- 92014 $89.53-

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2006 Medicare Fee Schedule2006 Medicare Fee ScheduleConsultationsConsultations

99241 $46.96- 99242 $86.00- 99243 $114.67- 99244 $162.01- 99245 $209.65-

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RefractionRefraction9201592015

Non-covered service Can be billed to beneficiary

– failure to do so results in lost revenues Reminders

– Charge only for “Rx-able” refractions– Do not forget to charge for the final refraction when changing

spectacles in a post-operative cataract patient

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GonioscopyGonioscopy9202092020

Bilateral Requires documentation

– describe visible angle structures No limitations to diagnostic groups in most states Fee $25.47

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Visual Field 9208xVisual Field 9208x

Bilateral Requires Interpretation

– separate report form– narrative in body of medical record, on date of service

Fee (-81) / $46.18 Fee (-82) / $59.09 Fee (-83) / $68.17

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Extended OphthalmoscopyExtended Ophthalmoscopy92225 / 9222692225 / 92226

Unilateral Initial (-225) vs. Subsequent (-226) Implies detailed, extra ophthalmoscopy

– document fundus lenses used Modifiers RT /LT Requires retinal drawings & interpretation

– sizes, colors and dimensions carrier specific Fee 92225 ($21.69) 92226 ($19.53)

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Fundus PhotographyFundus Photography9225092250

Bilateral Not Bundled Requires Interpretation Fee $69.46

Fundus Retinal Photos ROIFundus Retinal Photos ROI

Synemed (Canon 10+MP) Cost $24,500.00 Lease $543.90 Breakeven 2 photos / wk 8-10 MP digital non-

mydriatic 10 images / wk – lease =

$22,273.20 annual revenue

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Fluorescein Angiography 92235Fluorescein Angiography 92235Indocyanine-Green 92240Indocyanine-Green 92240

Unilateral Not Bundled Requires Interpretation & Report Fee 92235 ($122.55) 92240 ($254.30)

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External Ocular PhotographyExternal Ocular Photography9228592285

Report for documentation of medical progress– Ex.: close-up photography, slit lamp photography,

goniophotography, stereo-photography Bilateral Not Bundled Requires Interpretation and report Fee $42.12

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Special Anterior Segment PhotographySpecial Anterior Segment Photography9228692286

With specular endothelial microscopy and cell count– Ex: Konan specular microscope

Bilateral Not Bundled Requires Interpretation and report Fee $101.04

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364.00-364.04 iridocyclitits 364.10-364.11 chronic iridocyclitis 364.21 Fuch’s heterochromic iridocyclitis 364.22 glaucomatocyclitic crisis 364.23 lens induced iridocyclitis 364..24 VKH syndrome 364.51 essential iris atrophy 364.52 iridoschisis 364.53 pigmentary iris degeneration 364.54 pupillary margin degeneration

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364.55 Miotic Cysts of pupil margin 364.56-364.61 degenerative changes of anterior

structures 366.21-23 Traumatic cataract 366.32 cataract in inflammatory disorder 366.33 cataract in ocular neovascularization 371.20-24 corneal edemas 371.32-33 folds or rupture in descemet’s membrane 371.50, -.57,-.58, corneal dystrophy

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371.82 corneal edema due to contact lens 379.31 aphakia 379.32 subluxation of lens 379.32 anterior displacement of lens 743.20-23 buphthalmos 906.5 late effect of burn of eye/face 940.2 alkaline burn of cornea/conj 940.3 acid burn of cornea/conj 940.4 other burn of cornea/conj V42.5 cornea replaced by transplant

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996.51 mechanical complication of prosthetic corneal graft 996.60 infection/inflammation due to unspecified implant and

graft 996.69 complication of other implant or graft 998.89 complication of other transplanted organ 998.59 other postoperative infection 998.82 cataract fragments in eye following cataract surg V53.1 fitting & adjusting specs or CL after intraocular surgery

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Computerized Corneal TopographyComputerized Corneal Topography9202592025

Bilateral or unilateral Requires interpretation & report No limitations to diagnostic groups in most states Fee $23.12- / $28.47

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92025 Corneal Topography92025 Corneal Topography ICD-9 Codes that Support Medical Necessity

– 367.22* Irregular astigmatism– 371.00 Corneal Opacity Unspecified– 371.23 Bullous Keratopathy– 371.50 Hereditary Corneal Dystrophy Unspecified– 371.52 Other Anterior Corneal Dystrophy– 371.57 Endothelial Corneal Dystrophy– 371.60 Keratoconus Unspecified– 371.61 Keratoconus Stable Condition

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92025 Corneal Topography92025 Corneal Topography ICD-9 Codes that Support Medical Necessity

– 371.62 Keratoconus Acute Hydrops– 372.40 Pterygium Unspecified– 996.51 Mechanical Complication Prosthetic Corneal Graft– V42.5 Cornea Replaced by Transplant– V45.61* Cataract Extraction Status– V45.69* Other States Following Surgery of Eye /Adnexa– *367.22 must be accompanied by V45.61 or V45.69– *V45.61 must be accompanied by 367.22– *V45.69 must be accompanied by 367.22

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Therapeutic Contact LensTherapeutic Contact Lens9207092070

Unilateral Bundled with 92xxx, includes supply of lens Recommendations

– use disposable lenses– accept a less than optimum cosmetic fit– tolerate debris on and beneath lens– remove only once and do not replace– liberally hydrate prior to removal

Fee $58.93-/62.97

Collecting the Sample

4. Dab the sampling pad inside the lower eyelid (palpebral conjunctiva) 4 – 6 times. Allow the sampling pad to rest against the conjunctiva (membrane on inside of the eyelid) for an additional 3 seconds to ensure saturation of the sampling pad with eye fluid.

Test Procedure

RPS Adeno Detector™

Assembling the Detector

1. Locate the Test Cassette

2. Assemble the detector by gently placing the sampling pad of the Sample Collector into the sample transfer window of the Test Cassette body.

3. Press firmly where indicated until the detector is secure.

Test Procedure


Note: A double auditable click means the detector is properly assembled, transferring the sample to the test strip.

Transfer Window

Running the Test 1. Open the buffer vial. Remove

the Protective Cap from the Test Cassette. Do not allow any portion of the detector besides the absorbent tip to touch the buffer vial.

2. Immerse the Assembled Detector’s Absorbent Tip into the buffer vial for 15 seconds.

Test Procedure


Positive Results:

The Results Line and Control Line are RED in the result window, indicating that Adenovirus antigen is present.

Reading & Interpreting the Results


Control Line

Results Line

Control Line

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RPS AdenoDetectorRPS AdenoDetector8780987809

Bilateral Infectious agent detection by immunoassay with direct

observation, not otherwise specified Modifier: QW for CLIA waived products ICD-9 Positive test result

– 077.3 other adenoviral conjunctivitis; acute follicular conj– 077.99 other diseases of conjunctiva due to viruses

ICD-9 Negative test result– 372.02 Acute follicular conjunctivitis, excludes EKC, PCF– 372.05 Acute atopic conjunctivitis

Fee $17.76

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Serial TonometrySerial Tonometry9210092100

Bilateral Requires Interpretation & Report

– Example: Angle closure glaucoma– multiple measurements over time

Fee $85.60

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic ImagingDiagnostic Imaging

9213592135 Unilateral Applies to glaucoma and retinal evaluations

– Heidelberg / Heidelberg Retinal Topography (HRT3, Spectralis)– Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)– Optovue / (RTVue)– Marco / Retinal Thickness Analyzer (RTA)

Requires Interpretation & report Fee $45.64

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Scanning LaserScanning LaserCovered Diagnosis List Covered Diagnosis List

362.85 retinal nerve fiber bundle defects 377.00-377.04 364.22 glaucomatocyclitic crisis Papilledema 364.53 pigmentary iris degeneration 364.73 goniosynechiae 364.74 pupillary membranes 364.77 recession of the angle 365.00-365.9 glaucoma 368.40-368.45 visual field defects 377.9 unspecified disorder of optic nerve or pathways

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Scanning LaserScanning Laser9213592135

Moderate Damage - payable once or twice per year, not with a field– Visual field examples

moderate reduction in retinal sensitivity temporal wedge

– Optic Nerve examples enlarged cup with sloped or pale rim focal notch rim/disc >0.1 but <0.2 prominent lamina cribrosa

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Scanning LaserScanning Laser9213592135

Advanced Damage - rarely payable, fields more valuable– Visual field examples

loss of central vision temporal island remains severe reduction in retinal sensitivity absolute defects to within 3 degrees of fixation

– Optic Nerve examples rim destroyed rim/disc ratio<0.1

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PachymetryPachymetry7651476514

Bilateral Measurement of central corneal thickness (CCT) proven

by Ocular Hypertension Treatment Study (OHTS) to be standard of care in diagnosis and management of glaucoma, glaucoma suspect and ocular hypertension

Also billable for keratoconus, corneal transplants, cataracts with corneal dystrophies, guttata, edema

Requires Interpretation & Report Fee $11.42

Reichert IOPacReichert IOPac Portable Battery operated Stores up to 1000 pts. USB and infrared interface Down load to PC and

printer Detachable probe

– Easily replaced if necessary

– 888 849 8955

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Correction TrichiasisCorrection Trichiasis67820*67820*

Epilation By forceps ICD-9

– 374.05 Trichiasis without entropion– 374.01 Senile entropion

Fee $54.29

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Multiple Punctures of Multiple Punctures of Anterior CorneaAnterior Cornea

6560065600 Unilateral Stromal Tattoo 25 gauge needle ICD-9

– 371.70 Unspecified Corneal Deformity Fee $301.86

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Removal of Foreign BodyRemoval of Foreign Body65205*65205*

External Eye, Conjunctiva– superficial– scleral, non-perforating

ICD-9– 930.18 FB in cul-de-sac

Fee $48.82

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External Eye, Conjunctiva– embedded (includes concretions)– subconjunctival– scleral, non-perforating

ICD-9– 930.18 FB in other sites or combined sites

Fee $59.74

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External Eye, Corneal– with Slit Lamp

ICD-9– 930.0 FB in cornea

Fee $65.75

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Sensorimotor ExaminationSensorimotor Examination9206092060

Quantitative measurement of ocular deviation – document all major fields of gaze

Bilateral Requires interpretation and report Fee $48.93- 92065 – Orthoptic and / or pleoptic training, with

continuing medical direction and evaluation Fee $32.38

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Dilation of Lacrimal PunctaDilation of Lacrimal Puncta68801*68801*

With or Without Irrigation ICD-9

– 375.22 Epiphora, insufficiency of drainage– 375.42 Chronic Dacryocystitis– 375.52 Stenosis, Lacrimal Punctum– 375.56 Nasolacrimal Duct Obstruction

Fee $103.08

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Prolonged Physician ServiceProlonged Physician Service99354/9935599354/99355

Office or other outpatient setting Direct patient contact beyond the usual service List separately in addition to code for office or other

outpatient E/M service– <30min Not reported separately– 30-74min 99354 X 1 (Fee $84.88-/$93.36)– 75-104min 99354 X 1 and 99355 X 1– 105-134min 99354 X 1 and 99355 X 2

99355 - each additional 30 minutes (Fee $84.20/$92.33)

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Punctal Occlusion By PlugPunctal Occlusion By Plug6876168761

Temporary (collagen) or Permanent (Silicone) Payment is per puncta (modifiers required)

– E1=left upper E3=right upper– E2=left lower E4=right lower

Global period - 10 days Supply code-included in procedure code, not separately

billable Fee $130.02

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Punctal Occlusion By PlugPunctal Occlusion By Plug6876168761

ICD-9– 370.21 Punctate Keratitis– 370.23 Filamentary Keratitis– 370.34 Exposure Keratitis– 370.80 Other forms of Keratitis– 370.90 Unspecified Keratitis– 371.42 Recurrent Corneal Erosion– 374.41 Eyelid Retraction– 375.15 Unspecified Tear Film Insufficiency– 710.20 Sicca Syndrome; use additional systemic manif. code

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ModifiersModifiers– 79 Inside post-operative global period– 50 Bilateral Procedure– 24 Unrelated Service / Same Doctor– 79 Inside Global Period– 25 Separate Service / Same Doctor / Same Day – 52 Reduced Service / Informational / Not Reduced Fee– 54 Surgical Care Only– 55 Post-Op Care Only– 51 Multiple Procedures– RT / LT Right / Left– E 1- E4 Identifies Puncta

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Comanagement of SurgeryComanagement of Surgery

Procedures / 66984 / $639.69 Global Periods - usually 90 days Value - up to 20% Modifiers (-54,-55) Range Dates Rules - Medicare Transfer Agreement in MD record Correspondence Legal/Political/Inter-professional Issues

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Complicated Cataract Surgery Complicated Cataract Surgery 66982 66982

New CPT code for 2001 / $850.80 Extracapsular cataract extraction with insertion of

IOL, complex, requiring devices or techniques not generally used in routine cataract surgery– 2-3% of all cataract surgeries involve extraordinary work

iris expansion devices, suture support for IOL, posterior capsulorrhexis, small pupil, subluxed lens, Pseudoexfoliation, trauma, Marfan’s, glaucoma, uveitis

pediatric population Advanced, white, hard cataract

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CASE 1: CataractCASE 1: Cataract CPT / ICD

– 92015 / Myopia (367.1) = $20.00– 99203 / Cataract (366.16) = $95.00– Total $115.00

Rx: Spectacles RTO: 1YR CPT / ICD

– 92015 / Myopia (367.1) = $20.00– 99214 / Cataract (366.16) = $80.00– Total $100.00

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CASE 2: BlepharoconjunctivitisCASE 2: Blepharoconjunctivitis CPT / ICD

– 99213 or 92012 / Blepharitis (373.00) = $50.00 or $63.00 Rx: Bacitracin Oint hs / Tobradex qid / Lid Hygiene /

AFTs RTO: 1 WK CPT / ICD

– 99212 / Blepharitis (373.00) = $$45.00– Total $95.00 or $108.00

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CASE 3: Allergic ConjunctivitisCASE 3: Allergic Conjunctivitis CPT / ICD

– 99213 or 92012 / Conjunctivitis allergic (372.14)– $50.00 or $63.00

Rx: Pataday QD / Cold Packs / AFTs RTO: 1 WK CPT / ICD

– 99212 or 92012 / Conjunctivitis, allergic (372.14) = $$45.00 or $63.00

– Total $95.00 or $126.00

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CASE 4: Rosacea (Skin & Eye)CASE 4: Rosacea (Skin & Eye) CPT / ICD

– 99213 or 92012 Meibomianitis (373.12) / Acne Rosacea (695.30) = $50.00 or $63.00

– 92285 / (370.01) Marginal keratitis = $45.00– Total $ 95.00 or $108.00

Rx: Zylet QID / Lid Hygiene / Minocycline 50mg BID / MetroCream 0.75% BID RTO: 2 D

CPT / ICD– 99212 or 99213 / Meimbomianitis (373.12) = $50.00 or$63.00– Total $145.00 or 171.00

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CASE 5: Corneal Foreign BodyCASE 5: Corneal Foreign Body CPT / ICD

– 99213-25 / Abrasion (918.1) = $50.00– 99285 / Abrasion (918.1) = $45.00– 65222 / Corneal Foreign Body (930.00) = $65.00– Total $ 160.00

Rx: Acular LS QID / Zymar QID / Patch +/- Ibuprofen 400mg

RTO: 1 Day

JAM

CASE 6: Misdirected LashesCASE 6: Misdirected Lashes CPT / ICD

– 99213-25 / SPK (370.21) = $50.00– 92285 / SPK (370.21) = $45.00– 67820/ Trichiasis (374.05) = $45.00– Total $140.00

Rx: Xibrom BID / AFTs RTO: 1 Day / PRN

JAM

CASE 7: Corneal ErosionCASE 7: Corneal Erosion CPT / ICD

– 99213 / Recurrent Corneal Erosion (371.42) = $50.00– 92070 / Recurrent Corneal Erosion (371.42) = $70.00– Total $120.00

Rx: Vigamox TID / Nevanac TID / Bandage SCL RTO: 1 Day CPT / ICD

– 99212 or 92012 / Recurrent Corneal Erosion (371.42) = $45.00 or $63.00

– Total $165.00 or $183.00

JAM

CASE 8: Bacterial KeratitisCASE 8: Bacterial Keratitis CPT / ICD

– 99213 or 92012 / Bacterial Keratitis (370.03) = $50.00 or $63.00

– 92285 / Bacterial Keratitis (370.03) = $45.00– Total $95.00 or $108.00

Rx: Zymar q2h RTO: 1 Day E/M: 99212 or 99213 or…..?

– Total $145.00 and up

JAM

CASE 9: Central Serous RetinopathyCASE 9: Central Serous Retinopathy CPT / ICD

– 99213 / Central serous retinopathy (362.41) = $50.00– 92225-LT / Central serous retinopathy (362.41) = $20.00– 92250 / Central serous retinopathy (362.41) = $70.00– Total $140.00

Rx: Observation RTO: 1 Mos CPT / ICD

– 99213 / Central serous retinopathy (362.41) = $50.00– 92226-LT / Central serous retinopathy (362.41) = $20.00– 92135-LT / Central serous retinopathy (362.41) = $45.00– Total $255.00

JAM

CASE 10: Macular DegenerationCASE 10: Macular Degeneration CPT / ICD

– 99203 / Age Related Macular Degeneration (362.51) = $95.– 92225-RT, 92225-LT / (362.51) = $40.00– 92250 / (362.51) = $70.00– Total $205.00

Rx: Amsler Grid / Vitamins RTO: 6 Mos CPT / ICD

– 99212 / 92135-RT, 92135-LT / (362.51) = $135.00– Total $340.00

JAM

CASE 11CASE 11 CPT / ICD

– 99213 / Rheumatoid Arthritis (714.0), High Risk Medical Treatment (V58.69) = $50.00

– 92226-RT, 92226-LT / (714.0, V58.69) = $40.00– 92083 / (714.0, V58.69) = $70.00– Total $160.00

Rx: Observation RTO: 6 Mos CPT / ICD

– Same as above = $160.00– Total $320.00

JAM

CASE 12CASE 12

CPT / ICD– 99213 or 92012 / Dermatitis (373.32) = $50.00 or $63.00– 92285 / (373.32) = $45.00– Total $95.00 or $108

Hydrocortisone 1.0% QID / Cold Packs RTO: 1 WK CPT / ICD

– 99212 / (373.32) = $45.00– Total $140.00 – $153.00

JAM

CASE 13: Glaucoma SuspectCASE 13: Glaucoma Suspect CPT / ICD

– 99214 / Glaucoma Suspect (365.01) = $80.00– 92020 / (365.01) = $25.00– 76514 / (365.01) = $15.00– 92250 / (365.01) = $70.00– 92083 / (365.01) = $70.00

CPT / ICD – 99213 or 92012 / (365.01) = $50.00 or $63.00– 92235-RT, 92235-LT / (365.01) = $90.00– Total $400.00 or $413.00

Rx: Initiate or continue treatment or consultation-MD Use V58.69 in addition to ICD code when changing medications

in a glaucoma patient

JAM

CASE 14CASE 14 Dx: Documentation: Narrative & Shirmer Strips CPT / ICD Temporary Collagen Plugs

– 99214-25 / Dry Eye Syndrome (370.33) = $80.00– 68761-E2 / (370.33) = $125.00– 68761-E4 / (370.33) = $125.00 (Paid at 50% allowable)– Total $267.00

E/M: Permanent Silicone Plugs– 99212-25, 68761-E2, 68761-E4 / (370.33) = $227.00

RTO: >10 Days After Permanent Punctal Occlusion Total $494.00

JAM

CASE 15CASE 15 CPT / ICD

– 66984-55, RT / 366.16– Date of Service-is date of surgery– Range Dates-starts on date of transfer of care from MD to

OD, ends 90 days from date of surgery Rx: Post-Operative Care RTO: Outcome dependant E/M: 92015 and Material/Hardware Codes (DME)

Monitor Compliance with AuditsMonitor Compliance with Audits

Develop a “Documentation” team

Monthly Assessment– 10 charts/Provider

Report your Results– All staff, residents, students

Acknowledge positive & negative variances– RETRAIN, RETRAIN..

JAM

THANK YOU!THANK YOU! Primary Eyecare Network

– 1.800.444.9230 www.primaryeye.net– Medicare Compliance Kit

Health History Questionnaire Examination Forms E/M Worksheets ICD-9 Codes Interpretation/Report form

– Medicare A-Z Manual– Superbills / Signature on File stickers / Electronic Claims– HIPAA Compliance Manual

Thank youThank you

Excellence in Optometric EducationExcellence in Optometric Education

Missouri Eye Missouri Eye AssociatesAssociates

McGreal McGreal Educational Educational InstituteInstitute

Missouri Eye Missouri Eye AssociatesAssociates

McGreal McGreal Educational Educational InstituteInstitute

Excellence in Optometric Education

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