The Ultimate Compendium of Coding, Billing, and ... · 10/1/2015 · Medical Coding and Billing...
Transcript of The Ultimate Compendium of Coding, Billing, and ... · 10/1/2015 · Medical Coding and Billing...
The Ultimate Compendium of Coding, Billing, and Documentation Advice For
Ophthalmologists and Optometrists 2018 Edition
The EyeCodingForum
Jeffrey P. Restuccio, CPC, COC
Medical Coding and Billing Consultant
Over 250 pages, Softbound
$225 updated every year
One-hundred coding, billing and documentation concepts every Eyecare professional “must know.”
Over a dozen CMS-1500 actual coding examples.
Tips and advice from over 20 years of teaching coding and billing as well as over 10,000 chart audits.
Suitable for any level, beginner to advanced. In addition to sound coding and billing information in this book the author shares hundreds of Gotchas! (Exceptions), Coding Tips, Notes, and gray areas you won’t find anywhere else.
Includes an Index
To Order select the ORDER tab on the EyeCodingForum website and select the manual option.
Main Sections:
1. The Very Basics: For those new to medical coding.
2. 60 Key Coding Concepts: This is an expanded version of what I include in my Optimizing Compliance/Maximizing Revenue Seminar. I call these “must know” concepts. Most are kept to one page with additional information later in the manual. More concepts are introduced in later sections.
3. Office Visits: This includes content from three one-hour Webinars: Office Visits, Scoring Medical Decision Making and Medical Necessity.
4. Diagnostic Procedures and Small Surgical Procedures: These are the most common Eyecare procedures performed in the office.
5. Revenue Cycle: This is a catch-all term for issues involving front-office and back-office operations. Some are not specifically coding or billing related but extremely important. I also include topics related to management that will useful to ambitious coders and billers.
6. ICD-10: This is the short version with an emphasis on new codes. I have over ten hours of recorded ICD-10 training for Eyecare. I may offer a separate ICD-10 training manual for Eyecare if there is enough demand.
7. More on HCPCS and Modifiers: For those wanting additional formal coding training.
8. Optimizing Compliance: This is from my two-part series on Coding Compliance for Eyecare.
9. Maximizing Revenue: These are my top tips for getting every penny you deserve! (and always assume compliantly.) Each topic begins with TIP$. If you want pay for this manual and are experienced, jump ahead and review this section early.
10. DME-MAC and Post-Cataract Glasses: This is a different animal from Part-B billing and coding and office visits and procedures Clinics either love or hate selling post-cataract glasses. I cover the basics and offer tips for making this a winner in your clinic.
11. Additional Information: Too good to leave out but more advanced I included this information for the very ambitious or those who work for large clinics.
Below is the Table of Contents from the manual. In the beginning we cover basics in a succinct manner, most on one page to ensure everyone has a firm foundation in concepts.. Further in the manual several topics are expanded. Key topics of focus include: office visits, vision plans, the routine vision exam, comparing and contrasting E & M codes versus the Medicine Section codes (920xx), diagnostic tests, compliance, maximizing revenue, and dozens of real-world tips and “gotchas.” Forward 5
Table of Contents 6
Introduction 15
A Little Bit about the Author 16
Legend of Terms 17
Manual Organization 18
The Very Basics for Newbies 21
Different Types Of Healthcare Plans 21
The CMS-1500 Form 22
More Basic information 24
What is a Valid Source? 24
Over 60 Key Coding Concepts 25
Ranking of Guidelines 26
Clinical Resources 28
CPT© Codes 29
HCPCS codes 30
Modifiers 32
Small Surgical Procedures 33
Modifier 25 33
ICD-10 Codes 35
What is a Screening? 36
What is a Routine Vision Exam? 37
Long-Term Use of a High-Risk Drug 38
Office Visits 39
New versus Established Patients 39
920x2 Documentation Issues 40
920x4 Documentation Issues 40
Diagnostic Tests 41
Medical Necessity 42
Surgical Operative Reports 43
Co-Management 44
MOD-24: Unrelated E & M Service by the Same Physician during a Postoperative Period 45
NCCI Edits 46
Cloned Notes 47
Miscellaneous and Unlisted CPT™ codes 47
Software for Eyecare 48
Place of Service (POS) Codes48
Medicare and Medicare Guidelines 49
Medicare Jurisdictions 2017 Diagram 50
Medicare Jurisdictions 50
Medical Local Coverage Determinations 51
Incident-To Services (E & M Code 99211) 52
Medicare Modifier - GA 53
Medicare Modifier -GY 53
What is Medicare Advantage (MA)? 54
Medicaid 55
Vision Plans 55
Private Medical Insurance 57
Third-Party Administrator and Self-Funded Plans 57
Carrier-Specific Rules 58
Carrier-Specific Manual 58
Self-Pay Patients 59
What is a SOAP Note? 60
SNOCAMP 61
1997 versus 1995 Exam Guidelines 62
Counseling and Coordination of Care, Time 63
History: Chief Complaint (CC) 64
History of Present Illness (HPI) 65
Review of Systems (ROS) 65
Past, Family, Social History (PFSH): 67
E & M Levels 68
E & M Code Exam Elements 69
E & M: 2 of 3 Rule/3 of 3 Rule 70
Medical Decision Making (MDM) 71
Upcoding/Downcoding 72
CPT™ Category II Codes 75
CPT™ Category III Codes 77
Medicare PFSRVU Database 79
Relative Value Units (RVU’s) 79
Medicare Conversion Factor 79
More on RVUs 80
Bilateral Surgery Modifier 80
Global Period 81
Professional Component (MOD-26) 82
Technical Component (MOD-TC) 82
Interpretation and Report 83
What Exactly is a Red Flag? 84
Credentialing 87
HIPAA 87
MACRA/MIPS 90
Timely Filing Period 91
Legal Issues 92
Office Visits 93
Rules for Office Visit Documentation 93
Exam: Miscellaneous Notes 93
Diagnosis Problem Lists 94
Using MDM Table B: Data Reviewed 95
Medical Necessity and Office Visits 96
Medical Necessity Plan for Action 107
Diagnostic/Surgical Procedures for Eyecare 109
Bilateral Procedures 109
Global Periods 110
Reporting Diagnostic Procedures with an Office Visit on the same DOS 110
Gonioscopy 111
Corneal Topography 112
Angiography Codes 112
Serial Tonometry 113
Bandage Contact Lenses 113
Fundus Photography (92250) 115
Extended ophthalmoscopy (92225 and 92226) 115
OCT, GDX HRT, SCODI 116
External Ocular Photography 119
INTACS™ 119
Visual Field Exam codes 120
Corneal Pachymetry (76514) 120
Punctal Plugs 121
Epilation – Removal of an eyelash 122
Excision of a chalazion 123
More Coding and Billing Tips 124
Eyecare Surgical Procedures 125
Coding for Removing Rust Rings 126
Ophthalmologists Only 127
The Surgical Package 129
Minor Foreign Body removal Codes 130
IOL Master and Optical Coherence Biometry 131
Coding Compliance 135
The Mind of an Auditor 135
Types of Audits 136
Fraud and Abuse 136
The 50% (Auditing) rule 137
Seven Core Elements of a Compliance Plan 137
Compliance Checklist 138
Specific Audit Focus Examples 138
Documentation Consistency 138
Medical Records Tips 140
More on Cloned Notes 141
Common Office Visit Errors 142
What is a foreign body? 142
Glaucoma Suspect vs Probable Glaucoma 142
Dilation Contra-indications, Refusal, and Substitutions 143
Compliance Obstacles to Implementation 143
Top Gray areas in Eyecare Auditing 144
Maximizing Revenue Tips 147
TIP$: Do you sell supplements for ARMD? 147
TIP$: Special Codes 147
TIP$: Consultation Codes 148
TIP$: Linking Refraction Code 92015 to a Medical Diagnosis 149
TIP$: The Three Stable Conditions Rule 150
TIP$: Carrier Tips and Tricks 150
TIP$: Learn how to ask the question correctly 151
TIP$: Denial Management and Appeals 153
TIP$ Top Ten Medicare Part-B Denials (all specialties) 153
TIP$: “Casino” Health Insurance 154
TIP$: Twelve Appeal Steps 155
TIP$: Appeals Process (Medicare) 155
TIP$: Utilization Reviews 156
TIP$: National Specialty-Specific Manuals 157
TIP$: Maximizing Reimbursement Three Specific Eyecare Examples 158
TIP$: Setting Fees 159
TIP$: Additional Drugs with Adverse Affects 160
TIP$: Post Cataract Glasses billed to the DME-MAC 161
TIP$: Out of the Box Revenue Opportunities (for Optometrists) 162
TIP$: Other Place of Service (POS) Codes 162
TIP$: Correctional Facilities: Resources 163
TIP$: Vision Therapy Services 164
TIP$: Low Vision Services 164
TIP$: Eyecare Marketing: Ways to Impress 165
TIP$: Visual Evoked Potential 166
TIP$: Dual-Diagnosis Children Scenario 167
TIP$: Telemedicine and Eyecare 168
Revenue Cycle 169
Front Office Operations 169
Back Office Operations 169
Explanation of Benefits (EOB) 169
Coordination of Benefits (Care) (COB) 169
Crossover Claim 169
Write-Offs 170
Balance Billing 170
2018 ICD-10 Updates For Eyecare 171
ICD-10 Coding Highlights 180
The Big Picture 184
The AHA 2018 ICD-10 Coding Guidelines 188
ICD-10 Coding Specificity Example 188
ICD-10 Coding for Eyecare 190
Glaucoma Stages 190
DME-MAC Post cataract glasses 193
Marketing DME-MAC services 194
Post-Cataract Glasses Rules 195
Medically Necessary Options 196
Filing the Claim 198
Billing Example 198
Most Common DME-MAC Errors 201
Additional Information 205
CPT™ Modifiers 205
The 2015 “X” Modifiers 205
MOD-22 206
MOD-25 206
MOD-32: Mandated Services (rare) 207
MOD-50: Bilateral Procedures 208
MOD-52: Reduced Service 208
MOD-53: Discontinued Procedure 209
MOD-54, 55 & 56 209
MOD-57: Decision for Surgery 210
Mod-58 210
Mod -59: Distinct Procedural Service211
Surgical CPT™ Modifiers 211
Mod -62: Two Surgeons 211
MOD-66: Surgical Team 211
Mod-76 and 77 212
Mod -78: Return to the Operating Room 212
Mod -79: Unrelated Procedure 212
Mod -81: Minimum Assistant Surgeon 213
Mod -82: Assistant Surgeon 213
Mod -99: Multiple Modifiers 213
Resources For the Truly Dedicated 214
Searching for Information on the Internet 215
Conclusion 217
Coding and Billing for Eyecare Manual Index 218
Selected Sections:
What is a Screening?
There are actually four different types or definitions of “a screening.”
1. Any procedure performed in the absence of a diagnosis supporting medical necessity. The most common examples of diagnostic services performed as a screening include:
a. Fundus photography.
b. Pachymetry
c. External Photos
Always link a Routine Vision Exam (920xx code) to Z01.00 or Z01.01 if there is no presenting problem (and no medical codes to link to it.)
2. Specific screening codes
The two Medicare G HCPCS codes for glaucoma are specific screening codes. Medicare should pay on these two codes
G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist
Real World: Most clinics do not report these codes in actual practice. The main reason is that most Medicare-age patients will have a presenting problem that will support an office visit code.
3. An office visit and associated diagnostic tests linked to the screening for the long-term use of a high-risk drug like Plaquenil (for Rheumatoid arthritis), ICD-10 code: Z79.899. These should be always reimbursed by private medical, Medicare, and Medicaid. If not reimbursed I would appeal.
4. A Routine Vision Exam is a comprehensive eye exam for pathology (not a refraction exam) without a presenting problem or chief complaint. It is linked to the Z01.0- code. It is also called an annual exam or a well exam. The key is that it is a screening.
The concept that connects all of these is that there is no presenting problem. The chief complaint should be documented as a screening or Routine Vision Exam. Some screenings are reimbursed and others are not depending on type and carrier.
Gotcha! Refraction problems (anything H52.–) are not presenting problems. They should only be linked to 92015 and only paid as a refraction benefit (mostly Vision Plans).
WDIC? Screenings pose both an opportunity and a challenge–particularly for Optometrists. You must know which ones are paid and which ones are not. Not understanding the specific requirements for coding and reporting could cause denials.
What is a Routine Vision Exam?
As just explained, it’s considered a screening–but it is also more than that. There is no specific CPT™ Code for a routine eye exam. Most providers use 92014 because routine exams are overwhelmingly reported to a Vision Plan and not a Medical Plan (but there are exceptions). Even medical plans with a refraction benefit typically sub-contract the refraction portion to a Vision Plan such as VSP, EyeMed, Davis Vision, or Spectera.
Coding Tip: Always link your routine vision exam CPT™ code to ICD-10 codes Z01.00 or Z01.01, not a refraction code.
Coding Tip: A Routine Vision Exam is not a refraction exam! Technically a refraction exam is not included in a routine vision exam (although the majority of Vision Plans combine them into one payment). Most of your patients think of them as one service but they are not. They are two separate and discrete services.
Gotcha! Occasionally you will see an Eyecare coding article offering the two routine eye exam “S” codes below as an option. Only report these if the specific plan requires them. Otherwise do not report them. They are vague and poorly defined.
S0620: Routine ophthalmological examination including refraction; new patient
S0621: Routine ophthalmological examination including refraction; established patient
Always explain your patients that a Routine Vision Exam is a comprehensive exam for pathology (screening for a medical problem). It can include up to 14 exam elements. I repeat: it is not a refraction exam; that’s separate.
There are no universal Routine Vision requirements for dilation. It may be required per your Vision Plan contract. The state of Florida requires all new patients receive a dilated fundus exam. That is a state regulation.
Coding Tip: There is no national guideline or definition of what elements are included in a routine vision exam. This varies by state and school. Also your carrier contract could state what is required.
Gotcha! The word “routine” is no longer part of the ICD-10 code description.
Gotcha! Vision Plans don’t have to follow CPT™ or Medicare rules and guidelines!
Real World: It’s worth repeating that certain carriers, in particular Vision Plans and local Medicaid’s–make up their own rules. If they combine both the refraction exam and the routine vision exam into one code and make it one service, they can do that–even if it’s technically not accurate.
WDIC? Explaining what your comprehensive exam includes will help you compete with discount Eyecare clinics. This is confusing for the providers, staff, and the patients.
Medical Necessity
There are actually two definitions and applications:
1) Billing/CPT™ Codes: The most common definition is related to billing. Medical necessity is the one-to-one linking of a diagnosis to a CPT™ code to support reimbursement by the medical carrier. Some CPT™ codes are reimbursed on only a very specific diagnosis. Some CPT™ codes require two diagnoses (e.g., long-term use of a high risk drug).
The number one source for medical necessity information is the Local Coverage Determination available from your Medicare carrier. Private insurance companies sometimes will have bulletins with a list of ICD-10 codes that support medical necessity. This information is not in the CPT™ or ICD-10 manuals. It is strictly related to reimbursement by a carrier. Without documentation supporting medical necessity, the procedure is considered a screening and most medical plans will not reimburse the service.
Gotcha! Medical Necessity is the “Catch 22” of healthcare. You are only paid if you find a condition supporting medical necessity; but you may not know unless you perform the diagnostic test. Clinicians hate this.
If you suspect a lesion on the peripheral retina you may want to perform fundus photography to obtain an image and confirm. If you don’t find anything then the service is considered a screening and not reimbursable. But you won’t know unless you perform the service!
The best advice is to have the patient fill out an Advanced Beneficiary Notice (ABN) or similar form for a non-Medicare patient. The form must state they are responsible if the carrier does not pay and they understand they can refuse the service.
2) Office Visits: Medical necessity also refers to supporting the level and frequency of an office visit.
Coding Tip: Remember, that Vision Plans don’t care; they don’t require a presenting problem; there is no requirement for medical necessity. That’s the nature of a Routine Vision Exam. We will cover in more detail the Chief Complaint and the nature of the Presenting Problem later in this manual.
Gotcha! Refraction codes (H52.--) do not support a Routine Vision Exam (often reported with 92014) even though most all Vision Plans and a few medical plans may reimburse. Refraction codes have nothing to do with a 92014 code or any 920xx code. Link refraction codes only to 92015, refraction services.
The Ultimate Compendium of Coding, Billing, and Documentation Advice for Ophthalmologists and Optometrists: 2018 Edition includes 125 test questions to reinforce learning. Below are 25 questions from the manual. 1) With the advent of ICD-10, state Worker’s Compensation Boards:
Answer 1: All decided to stay with ICD-9. Answer 2: Had an option of adopting ICD-10 on the Oct 1 2015 date or continue with ICD-9. Answer 3: Were mandated to adopt ICD-10 on Oct. 1 2015 just like Medicare, Medicaid and all private insurance carriers. Answer 4: None of the statements above are correct. 2) Where and what is the uvea of the eye?
Answer 1: It includes three contiguous structures: the iris, ciliary body, and the choroid. Answer 2: It is a ring of fibrous strands that connects the ciliary body with the crystalline lens of the eye. Answer 3: It is in the posterior segment Answer 4: None of the Answers are Correct. 3) The AMA CPT Assistant is:
Answer 1: Is a widely acclaimed certification title. Answer 2: A valuable coding resource. Answer 3: Applies only to primary care. Answer 4: None of the Answers are Correct. 4) What is a drawback of an HMO?
Answer 1: Providers have an incentive to keep treatment costs at a minimum. Answer 2: The HMO administrators determine what services are reimbursed and what is not. Answer 3: The provider is now a gatekeeper to the patient's medical care. Answer 4: All of the Answers are Correct. 8) If Medicare guidelines don't agree with AMA CPT Guidelines, which one do you go with?
Answer 1: Medicare Answer 2: AMA CPT Guidelines Answer 3: Neither Answer 4: Go with whichever agrees with the state Medicaid Guidelines
9) Eye exam codes S0620 and S0621:
Answer 1: May be used for self-pay patients Answer 2: Are used by some Medicaid carriers Answer 3: Are used for new or established routine office visits and include refraction.
Answer 4: All of the Answers are Correct. 10) Which of the following is NOT descriptive of HCPCS G codes?
Answer 1: They are temporary codes. Answer 2: They are assigned by CMS. Answer 3: They are under review by the AMA for CPT inclusion. Answer 4: They include durable medical equipment (DME). 11) When should you use CPT code 99070?
Answer 1: CPT states this code should be used for all supplies. Answer 2: Only use this code for Medicare Answer 3: Only use this code for Vision Plans. Answer 4: Only if a carrier requires its use in writing.
12) Modifiers E1 through E4 describe what?
Answer 1: Nothing to do with the eye. Answer 2: Denote which eyelid, upper or lower and right or left. Answer 3: Denote which and what part of the eyeball. Answer 4: Describe the level of impairment for cataract cases. 13) How is modifier 25 used?
Answer 1: Use it to report the professional component only. Answer 2: Use it to report unusual anesthesia (in the office). Answer 3: When a small surgical office procedure and an Evaluation and Management (E & M) code are reported on the same Day of Service
Answer 4: None of the Answers are Correct. 14) How is a chemical burn of the cornea reported in ICD-10?
Answer 1: Use the ICD-10 burn codes: T26.1-x-. Add laterality and occurrence character. Answer 2: Use the ICD-10 corrosion codes T26.6-X- Answer 3: There is no specific code for a chemical burn. Answer 4: Report it as a foreign body using the T15.--X- codes.
15) Specific ICD-10 codes for pterygium include options for nasal and temporal?
Answer 1: TRUE Answer 2: FALSE Answer 3:
Answer 4:
16) Screenings are never paid because there is no presenting problem.
Answer 1: TRUE Answer 2: FALSE Answer 3:
Answer 4:
17) An adverse effect can be from:
Answer 1: A correct substance taken in the wrong amount. Answer 2: A substance not normally ingested. Answer 3: A correct substance taken in the correct amount. Answer 4: Any accident, injury, or poisoning. 18) What type of office visit would not support any 920x2 encounter?
Answer 1: A resolved-problem follow-up encounter. Answer 2: A new patient. Answer 3: A routine eye exam. Answer 4: A new diagnosis. 19) The 920x4 comprehensive exam:
Answer 1: Requires dilation, EOM, CF, and the initiation of something. Answer 2: Requires external ocular adnexa, EOM, CF, and the initiation of something.
Answer 3: Requires dilation, EOM, CF, and external ocular adnexa. Answer 4: Requires dilation, external ocular adnexa, EOM, CF, and a new diagnosis.
20) Medical necessity information is found in:
Answer 1: The ICD-10 manual Answer 2: The CPT manual Answer 3: HCPCS manual Answer 4: None of the Answers are Correct.
21) What are NCCI edits and what is their significance?
Answer 1: National Correct Coding Initiative; edits not found in the CPT manual. Answer 2: National Correct Claims Initiative; Linking of CPT codes to the ICD-10 codes. Answer 3: National Correct Coding Initiative; these guidelines are in the CPT
Answer 4: These are age and sex edits for claims submission. 22) What is the rule for using an E&M code versus using a 992xx Exam code?
Answer 1: Always use an E & M code for a medical diagnosis. Answer 2: Always use a 920xx Exam code when the eyes are dilated. Answer 3: Always use a Level 5 E & M code when you report all 14 Exam
Answer 4: Use the code and level that is supported by the documentation. 23) When is time a key factor when assigning a level to an E & M Code?
Answer 1: Never Answer 2: Time is always a factor Answer 3: Time is a factor only when counseling or Coordination of Care dominates the encounter.. Answer 4: The three Key factors are Time, Exam and History for an office visit. 24) What is the 2 of 3 rule?
Answer 1: This is an E & M guideline stating that for an established patient only two of the three key components (history, exam, and medical decision making) are required to be at the reported level. Answer 2: If 2 of 3 doctors report the service that way then the insurance company will accept it. Answer 3: if three services are provided on the same day of service the insurance company will only pay for two. Answer 4: None of the Answers are Correct. 25) Can the optometrist substitute a visual field exam for a confrontation field (as an Exam element) ?
Answer 1: Yes Answer 2: While many providers consider the visual field exam a better test, there are currently no Medicare guidelines stating this can be done. Answer 3: No Answer 4: Currently about half of the Medicare carriers allow it.