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Basics of Coding and Billing Basics of Coding and Billing for the Optometric Stafffor the Optometric Staff

Jonathan Cargo, O.D.Cargoeyecare.comJonathancargo@yahoo.com

What is CodingWhat is Coding

A system of diagnosis and procedure codes to A system of diagnosis and procedure codes to describe an encounter, procedure, diagnostic describe an encounter, procedure, diagnostic test, or supplies provided to a patient.test, or supplies provided to a patient.

Centers for Medicare & Medicaid Services (CMS)Centers for Medicare & Medicaid Services (CMS)National Correct Coding Initiative (NCCI) National Correct Coding Initiative (NCCI) Manual is updated annually.Manual is updated annually.

http://http://www.cms.hhs.gov/NationalCorrectCodInitEdwww.cms.hhs.gov/NationalCorrectCodInitEd//

Vision Plan vs. Health InsuranceVision Plan vs. Health Insurance

Vision PlansVision PlansCoverage for routine wellness examinationsCoverage for routine wellness examinations

Some cover contact lens fitting servicesSome cover contact lens fitting services

May cover hardwareMay cover hardwareContact lenses, frames and spectaclesContact lenses, frames and spectacles

Usually have a fixed amount that they contribute.Usually have a fixed amount that they contribute.Some may only be discounted plansSome may only be discounted plans

Usage is typically limited to once/ yearUsage is typically limited to once/ yearFrequently limit your coding abilityFrequently limit your coding ability

Vision Plan vs. Health InsuranceVision Plan vs. Health Insurance

Health Insurance Health Insurance Covers medical eye conditionsCovers medical eye conditions

Office VisitsOffice VisitsDiagnostic TestingDiagnostic TestingSurgical ProceduresSurgical ProceduresOffice ProceduresOffice Procedures

May Cover Refractions?May Cover Refractions?

Subject to CoSubject to Co--payments and deductiblespayments and deductiblesUsually has few restrictions on number of office visits Usually has few restrictions on number of office visits allowed. allowed.

Health InsuranceHealth Insurance

CoCo--payment (Copayment (Co--insurance)insurance)Is the amount paid by the insured person each time a medical service is accessed

Sometimes this can be a fixed amount or a percentage of the allowed amount.

Deductibleportion of any claim that is not covered by the insurance provider.The deductible must be paid by the insured, before the benefits The deductible must be paid by the insured, before the benefits of the of the policy can apply.policy can apply.

This payment should be collected from the patient at the time seThis payment should be collected from the patient at the time services are rvices are delivered. delivered. Most office visits that have a fixed coMost office visits that have a fixed co--pay the deductible does not apply to pay the deductible does not apply to the office visit onlythe office visit onlyMost percentage based coMost percentage based co--payments require a person must meet their payments require a person must meet their deductible before any payment is made by the third party.deductible before any payment is made by the third party.

The deductible amount usually starts over each calendar yearThe deductible amount usually starts over each calendar year

Coding TerminologyCoding Terminology

Procedure codesProcedure codesCPTCPT--55

Current procedural Terminology, 5Current procedural Terminology, 5thth Ed.Ed.Diagnosis CodesDiagnosis Codes

ICDICD--99--CMCMInternational Classifications of Diseases, 9International Classifications of Diseases, 9thth Revision, Clinical ModificationsRevision, Clinical Modifications

ICDICD--10 on October 1, 201310 on October 1, 2013

Material CodesMaterial CodesHCPCSHCPCS

Health Care Procedures Coding SystemHealth Care Procedures Coding SystemPharmaceutical CodesPharmaceutical Codes

AHFSAHFSAmerican Hospital Formulary ServiceAmerican Hospital Formulary Service

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Rules for billingRules for billing

The diagnosis (ICDThe diagnosis (ICD--99--CM) must relate to the CM) must relate to the procedure (CPT) codeprocedure (CPT) code

Local Area Determination (LCD) will often tell you Local Area Determination (LCD) will often tell you what ICDwhat ICD--9 code is allowed for a CPT code9 code is allowed for a CPT code

http://http://www.trailblazerhealth.comwww.trailblazerhealth.com

The doctor should code every patientThe doctor should code every patientThe reason for the visit determines the coverageThe reason for the visit determines the coverage

Depends on the purpose of the examination rather Depends on the purpose of the examination rather than the ultimate diagnosis of the patientthan the ultimate diagnosis of the patient’’s conditions condition

Best Practice IdeasBest Practice Ideas

Verify both health insurance and vision Verify both health insurance and vision plan prior to every office visit.plan prior to every office visit.

Insurance plans frequently changeInsurance plans frequently changeScan or copy image of insurance card and Scan or copy image of insurance card and photo ID. photo ID. Inform the patient what deductibles and Inform the patient what deductibles and coco--pays will be collected prior to seeing pays will be collected prior to seeing the patient. the patient.

Clean ClaimClean Claim

Simply one that the third party payer Simply one that the third party payer processes automatically without human processes automatically without human review. review.

This is done through standard coding and This is done through standard coding and using CPT and ICDusing CPT and ICD--9 9 Most plans have a set period of time that you Most plans have a set period of time that you have to submit a clean claim from the date of have to submit a clean claim from the date of service. service.

CPT (procedure) Code CategoriesCPT (procedure) Code Categories

92000 Ophthalmology Codes92000 Ophthalmology Codes99000 Evaluation and Management Codes99000 Evaluation and Management Codes60000 Surgical Codes60000 Surgical Codes70000 Radiological Codes70000 Radiological Codes80000 Laboratory Codes80000 Laboratory Codes

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Ways to Code ExaminationsWays to Code Examinations

S codes Routine Eye examinationsS codes Routine Eye examinations92000 Examination Codes92000 Examination Codes

Special Special OphthalmogicalOphthalmogical ProceduresProcedures

99000 Evaluation and Management99000 Evaluation and ManagementConsultationsConsultations

What is a New Patient?What is a New Patient?

A new patient is one who has not received any A new patient is one who has not received any professional service from any doctor who professional service from any doctor who belongs to the same group practice within 3 belongs to the same group practice within 3 years.years.

Wellness ExaminationWellness Examination

S codes are Level II HCPSC codesS codes are Level II HCPSC codesS0620 S0620 –– New patient routine New patient routine OphthalmologicalOphthalmological examination with refraction examination with refraction S0621 S0621 –– Established patient routine Established patient routine OphthalmologicalOphthalmological examination with refractionexamination with refraction

Texas Medicaid is one the first major payer to Texas Medicaid is one the first major payer to recognize this code.recognize this code.

Medicare does not reimburse for wellness examsMedicare does not reimburse for wellness examsMany Vision plans have not yet adopted this codeMany Vision plans have not yet adopted this code

General General OphthalmologicalOphthalmologicalExamination CodesExamination Codes

Comprehensive Comprehensive OphthalmologicalOphthalmological ExamExam92004 92004 -- New PatientNew Patient92014 92014 -- Established patientEstablished patient

Intermediate Intermediate OphthalmologicalOphthalmological ExamExam92014 92014 –– New PatientNew Patient92012 92012 –– Established PatientEstablished Patient

Comprehensive Comprehensive OphthalmolgicalOphthalmolgical Services(92004)Services(92004)

A level of service in which a general evaluation of the completeA level of service in which a general evaluation of the complete visual visual system is madesystem is made

WhatWhat’’s requireds requiredHistoryHistoryGeneral medical observationGeneral medical observationExternal and internal External and internal OpthalmoscopicOpthalmoscopic examinationexaminationGross visual fieldsGross visual fieldsBasic sensory motor examinationBasic sensory motor examination

These definitions are not at strict as E/M codes These definitions are not at strict as E/M codes Please note Refraction is not included in this definition.Please note Refraction is not included in this definition.

Intermediate Intermediate OphthalmologicalOphthalmologicalServices (92014)Services (92014)

Describes a level of service pertaining to the evaluation Describes a level of service pertaining to the evaluation of a new or existing condition complicated with a new of a new or existing condition complicated with a new diagnostic or management problem not necessarily diagnostic or management problem not necessarily relating to the primary diagnosisrelating to the primary diagnosis

HistoryHistoryGeneral medical observationGeneral medical observationExternal ocular and External ocular and adnexaladnexal examination examination Other diagnostic procedures as indicatedOther diagnostic procedures as indicatedMay include the use of May include the use of mydriasismydriasis

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Evaluation and management codesEvaluation and management codes

E/M Codes can also be used to describe an eye examinationE/M Codes can also be used to describe an eye examinationMore and better documentation is required for the 99000 codesMore and better documentation is required for the 99000 codesThree components of E/M codes are Three components of E/M codes are

HistoryHistoryExaminationExaminationDecision makingDecision making

New Patient: New Patient: 99201, 99202, 99203, 99204, 9920599201, 99202, 99203, 99204, 99205

Established PatientEstablished Patient99211, 99212, 99213, 99214, 9921599211, 99212, 99213, 99214, 99215

Evaluation and management codesEvaluation and management codes

HistoryHistoryChief ComplaintChief Complaint

A concise statement describing the symptoms, problem, condition,A concise statement describing the symptoms, problem, condition,diagnosis, physician recommended return, or other factor that isdiagnosis, physician recommended return, or other factor that is the the reason for the encounter, usually stated in the patients words. reason for the encounter, usually stated in the patients words. Medical insurance also covers ongoing examinations or treatment Medical insurance also covers ongoing examinations or treatment for for existing conditions. existing conditions.

History of present Illness (HPI)History of present Illness (HPI)Is a chronological description of the development of the patientIs a chronological description of the development of the patient’’s s present illness from the first sign or symptompresent illness from the first sign or symptomThere are eight areas and two levels of a HPI history There are eight areas and two levels of a HPI history

4 or more then you have a high level of history 4 or more then you have a high level of history Extended HPIExtended HPI

Less than 4 elements then you have a brief HPI Less than 4 elements then you have a brief HPI Brief HPI Brief HPI

E/M Coding: HPI ElementsE/M Coding: HPI Elements

No, Headache, NauseaNo, Headache, NauseaAre there associated symptoms?Are there associated symptoms?Associated Associated symptomssymptoms

Short term, long termShort term, long termHow long has the problem been How long has the problem been present?present?

TimingTiming

Intermittent, Constant Intermittent, Constant How long does the problem last?How long does the problem last?DurationDuration

Distance, Near, BothDistance, Near, BothIs it worse at any distance?Is it worse at any distance?Modifying Modifying factorsfactors

Mild, Moderate, SevereMild, Moderate, SevereHow severe is the problem?How severe is the problem?SeveritySeverity

Sudden or graduallySudden or graduallyDid the problem occur?Did the problem occur?ContextContext

Vision Loss or BlurVision Loss or BlurDoes the problem cause?Does the problem cause?QualityQuality

Right; Left; BothRight; Left; BothWhich eye has a problem?Which eye has a problem?LocationLocation

ResponseResponseQuestionQuestionHPI HPI AreaArea

Evaluation and management codesEvaluation and management codes

HistoryHistoryPast, Family and Social History (PFSH)Past, Family and Social History (PFSH)

There are two levels of PFSHThere are two levels of PFSHReview of the area directly related to the problemReview of the area directly related to the problem

Pertinent Pertinent PFSHPFSHHighest level = 2 or more elements Highest level = 2 or more elements

Complete Complete PFSHPFSHFor a new patient you must document all three areas.For a new patient you must document all three areas.

Review of Systems (ROS)Review of Systems (ROS)Review of systems has three levelsReview of systems has three levels

Review of one system = Review of one system = Problem PertinentProblem PertinentReview of 2Review of 2--9 systems = 9 systems = ExtendedExtended ROSROSReview of 10 or more systems = Review of 10 or more systems = CompleteComplete ROS ROS

It is not enough to make the statement It is not enough to make the statement ““All systems NegativeAll systems Negative””

What are the Systems?What are the Systems?

ConstitutionalConstitutionalEyesEyesEars, Nose, Mouth, Ears, Nose, Mouth, ThroatThroatCardiovascularCardiovascularRespiratoryRespiratoryGastrointestinalGastrointestinalGenitourinaryGenitourinary

MusculoskeletalMusculoskeletalIntegumentaryIntegumentary (skin)(skin)NeurologicalNeurologicalPsychiatricPsychiatricEndocrineEndocrineHematological (blood)/ Hematological (blood)/ LymphaticLymphaticAllergic/ ImmunologicalAllergic/ Immunological

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Classification of HistoryClassification of History

CompleteCompleteCompleteCompleteExtendedExtendedComprehensiveComprehensive

PertinentPertinentExtendedExtendedExtendedExtendedDetailedDetailed

N/AN/AProblem PertinentProblem PertinentBriefBriefExpanded Expanded Problem FocusedProblem Focused

N/AN/AN/AN/ABriefBriefProblem focusedProblem focusedPFSHPFSHROSROSHPIHPIType of HistoryType of History

Evaluation and management codesEvaluation and management codes

ExaminationExaminationProblem focusedProblem focused

11--5 examination elements5 examination elements

Expanded problem focusedExpanded problem focused6 or more examination elements6 or more examination elements

Detailed examinationDetailed examination9 or more examination elements9 or more examination elements

Comprehensive examinationComprehensive examinationAll elementsAll elements

Examination ElementsExamination Elements

Visual AcuityVisual AcuityGross visual field testing by confrontationGross visual field testing by confrontationOcular motility including primary gaze alignmentOcular motility including primary gaze alignmentInspection of bulbar and Inspection of bulbar and palpebralpalpebral conjuntivaconjuntivaExamination of ocular Examination of ocular adnexaeadnexae (area around the eye)(area around the eye)Examination of pupils and irises including shape, direct and conExamination of pupils and irises including shape, direct and consensual reaction, size, and sensual reaction, size, and morphologymorphologySlit lamp examination of the corneas including epithelium, Slit lamp examination of the corneas including epithelium, stromastroma, endothelium, and tear , endothelium, and tear filmfilmSlit lamp examination of the anterior chambers, including depth,Slit lamp examination of the anterior chambers, including depth, cells, and flare. cells, and flare. Slit lamp examination of the lenses including clarity, anterior Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and posterior capsule, cortex, and nucleusand nucleus. . Measurement of intraocular pressuresMeasurement of intraocular pressuresUnless contraindicated, Unless contraindicated, ophthalmoscopicophthalmoscopic examination through dilated pupils of optic discs examination through dilated pupils of optic discs including size, C/D Ratio, appearance, and nerve fiber layerincluding size, C/D Ratio, appearance, and nerve fiber layerUnless contraindicated, Unless contraindicated, ophthalmoscopicophthalmoscopic examination through dilated pupils of posterior examination through dilated pupils of posterior segments including retina and vesselssegments including retina and vesselsBrief assessment of mental status including orientation to time,Brief assessment of mental status including orientation to time, place and personplace and personBrief assessment of mental status including mood and affect.Brief assessment of mental status including mood and affect.

E&M: Medical Decision MakingE&M: Medical Decision Making

HighHighExtensiveExtensiveExtensiveExtensiveHigh High ComplexityComplexity

ModerateModerateModerateModerateMultipleMultipleModerate Moderate ComplexityComplexity

LowLowLimitedLimitedLimitedLimitedLow ComplexityLow Complexity

MinimalMinimalMinimal Minimal MinimalMinimalStraightforwardStraightforward

Risk of Risk of complication complication and/or and/or morbidity or morbidity or mortalitymortality

Amount Amount and/or and/or complexity of complexity of data to be data to be reviewedreviewed

Number of Number of diagnoses or diagnoses or management management optionsoptions

Type of decision Type of decision makingmaking

E & M coding: New PatientE & M coding: New Patient3 Elements must be met or exceeded3 Elements must be met or exceeded

High ComplexityHigh ComplexityComprehensiveComprehensiveComprehensiveComprehensive9920599205

Moderate Moderate ComplexityComplexity

ComprehensiveComprehensiveComprehensiveComprehensive9920499204

Low ComplexityLow ComplexityDetailedDetailedDetailedDetailed9920399203

Straight ForwardStraight ForwardExpanded P.F.Expanded P.F.Expanded P.F.Expanded P.F.9920299202

Straight ForwardStraight ForwardProblem Problem FocusedFocused

Problem Problem FocusedFocused

9920199201

Decision makingDecision makingExamExamHistoryHistory

E & M coding: Established PatientE & M coding: Established Patient2 Elements must be met or exceeded2 Elements must be met or exceeded

High ComplexityHigh ComplexityComprehensiveComprehensiveComprehensiveComprehensive9921599215

Moderate Moderate ComplexityComplexity

DetailedDetailedDetailedDetailed9921499214

Low ComplexityLow ComplexityExpanded P.F.Expanded P.F.Expanded P.F.Expanded P.F.9921399213

Straight ForwardStraight ForwardProblem Problem FocusedFocused

Problem Problem FocusedFocused

9921299212

MinimalMinimalMinimalMinimalMinimalMinimal9921199211

Decision makingDecision makingExamExamHistoryHistory

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E&M ExamplesE&M Examples

Established patient who has a comprehensive history a Established patient who has a comprehensive history a comprehensive exam and moderate decision making comprehensive exam and moderate decision making

9921599215

New patient has a comprehensive history, a detailed New patient has a comprehensive history, a detailed exam and straightforward medical decision making. exam and straightforward medical decision making.

9920299202

An established patient has a comprehensive history, a An established patient has a comprehensive history, a detailed exam and straightforward medical decision detailed exam and straightforward medical decision makingmaking

9921499214

Surgical codesSurgical codes

You cannot bill for an office visit on the same You cannot bill for an office visit on the same day as surgical code using the same diagnosis.day as surgical code using the same diagnosis.

You can however bill if there is a significantly You can however bill if there is a significantly separate diagnosis for each procedureseparate diagnosis for each procedure

Surgical codes usually have a global period that Surgical codes usually have a global period that includes follow up care.includes follow up care.

Example: Example: PunctalPunctal plugs = 10 daysplugs = 10 days

The second procedure on the same day is The second procedure on the same day is always reimbursed at 50% of the allowed always reimbursed at 50% of the allowed amount. amount.

Special Special OphthalmologicalOphthalmological ServicesServices

Describes services in which a special evaluation of part of the Describes services in which a special evaluation of part of the visual system visual system is made, which goes beyond the services included under general is made, which goes beyond the services included under general ophthalmologicalophthalmological services.services.

92015 Refraction92015 Refraction 92020 Gonioscopy92020 Gonioscopy92060 92060 SensorimotorSensorimotor 92065 92065 OrthopticOrthoptic treatmenttreatment92070 Fitting of contact lens for92070 Fitting of contact lens for 92100 Serial Tonometry92100 Serial Tonometry

diseasedisease 92286 92286 SpecularSpecular MicroscopyMicroscopy92225 Extended ophthalmoscopy92225 Extended ophthalmoscopy 92250 Fundus Photography92250 Fundus Photography92226 Subsequent 92226 Subsequent opthalmoscopyopthalmoscopy 92285 External Photography92285 External Photography92082 Intermediate VF92082 Intermediate VF 92135 Scanning Laser 92135 Scanning Laser OphthOphth. . 92083 Threshold VF92083 Threshold VF 92283 Color Vision exam92283 Color Vision exam92140 Provocative Glaucoma test92140 Provocative Glaucoma test

ConsultationsConsultations

A consultation is a type of service provided by a A consultation is a type of service provided by a physician whose opinion or advice regarding E&M of a physician whose opinion or advice regarding E&M of a specific problem is requested by another physician or specific problem is requested by another physician or other appropriate source. There must be a report back other appropriate source. There must be a report back to the requesting physician or other appropriate source.to the requesting physician or other appropriate source.

Three types of consultations codesThree types of consultations codesOffice Office

9924199241--9924599245Initial inpatientInitial inpatient

9925199251--9925599255FollowFollow--up inpatientup inpatient

9926199261--9926599265

Consultation: Office Consultation: Office 9924199241--9924599245

These codes are used to report consultations provided in These codes are used to report consultations provided in the physicianthe physician’’s office when another physician sends a s office when another physician sends a patient to your office for a specific medical sign or patient to your office for a specific medical sign or symptoms. symptoms.

You must have a written request from the physician requesting a You must have a written request from the physician requesting a consultation from you.consultation from you.You must send a letter back to the referring physicianYou must send a letter back to the referring physicianThe consultation code can only be used on the first visit The consultation code can only be used on the first visit

Follow up visits in the consultantFollow up visits in the consultant’’s office after the initial visits s office after the initial visits should be coded using establish E&M coding. should be coded using establish E&M coding.

CMS has eliminated the use of these codes as of Jan. 1, 2010.CMS has eliminated the use of these codes as of Jan. 1, 2010.Private insurance usually follows. Private insurance usually follows.

Modifier CodesModifier CodesModifier Codes indicate a unusual services, multiple procedures,Modifier Codes indicate a unusual services, multiple procedures, surgical cosurgical co--management, and break down management, and break down procedures into their components. procedures into their components.

22: Greater than normal service22: Greater than normal service25: Significant, separate identifiable E&M service by same pro25: Significant, separate identifiable E&M service by same provider on the same day vider on the same day 26: Professional component26: Professional component50: Bilateral procedure50: Bilateral procedure51: Multiple procedures performed on the same day51: Multiple procedures performed on the same day52: Reduced services52: Reduced services55: Post operative management only55: Post operative management only56: Pre operative management only 56: Pre operative management only 59: Significant, separate identifiable procedure by same provi59: Significant, separate identifiable procedure by same provider on the same dayder on the same dayTC: Technical ComponentTC: Technical ComponentRT: RightRT: RightLT: LeftLT: LeftE1: Right Superior Eye LidE1: Right Superior Eye LidE2: Right Inferior Eye LidE2: Right Inferior Eye LidE3: Left Superior Eye LidE3: Left Superior Eye LidE4: Left Inferior Eye Lid E4: Left Inferior Eye Lid GY: Statutorily not covered by Medicare GY: Statutorily not covered by Medicare

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Bilateral Bilateral vsvs UnilateralUnilateral

Unilateral codesUnilateral codesReimburse per eyeReimburse per eye

You could perform on just one eyeYou could perform on just one eyeIf you perform on both eyes you could use the modifier (50)If you perform on both eyes you could use the modifier (50)

Better option is to list the procedure on two lines and indicateBetter option is to list the procedure on two lines and indicate RT and LFRT and LFExample: Scanning Laser Example: Scanning Laser OphthalmoscopyOphthalmoscopy 9213592135

Bilateral codesBilateral codesAre designed to be performed on both eyesAre designed to be performed on both eyes

If you only perform it on one eye then your such you a 52 modifiIf you only perform it on one eye then your such you a 52 modifier er ––reduced services to indicate only one eyereduced services to indicate only one eyeExample: Example: FundusFundus Photos Photos –– 9225092250

Unilateral or BilateralUnilateral or BilateralYou would code it and be reimbursed the same if you perform the You would code it and be reimbursed the same if you perform the procedure on one or two eyes. procedure on one or two eyes.

Example: Threshold Visual Field Example: Threshold Visual Field -- 9208392083

Components Components

Most diagnostic procedures can be broken down Most diagnostic procedures can be broken down into their components using modifiers.into their components using modifiers.

TC TC –– Technical component. Technical component. Reimbursing the cost of the equipmentReimbursing the cost of the equipment

26 26 –– Professional componentProfessional componentReimburses the doctorReimburses the doctor’’s interpretation of the datas interpretation of the data

Without the modifiers then you receive Without the modifiers then you receive both components both components

Diagnosis Codes: ICDDiagnosis Codes: ICD--99--CMCM

The first diagnosis code you list should be for the chief complaThe first diagnosis code you list should be for the chief complaint int that brought the patient into your office.that brought the patient into your office.Use the exact code for each diagnosis.Use the exact code for each diagnosis.Code the patientCode the patient’’s condition to the highest degree of certainty for s condition to the highest degree of certainty for that appointmentthat appointmentYou may report treatments as many times as you provide them for You may report treatments as many times as you provide them for a chronic condition that your are treating on an ongoing basis. a chronic condition that your are treating on an ongoing basis. When coding for a postoperative diagnosis that is different fromWhen coding for a postoperative diagnosis that is different fromthat given prior to surgery, code for the postoperative diagnosithat given prior to surgery, code for the postoperative diagnosis.s.

Example Example psuedophakiapsuedophakiaSupply a code for any coSupply a code for any co--existing conditions that require or affect existing conditions that require or affect patient care at the time of the patientpatient care at the time of the patient’’s appointment. s appointment.

Best Practice IdeasBest Practice Ideas

Never record in a patientNever record in a patient’’s chief complaint s chief complaint that they are there for a that they are there for a ““Routine eye Routine eye examexam”” or or ““Needs new contacts/glassesNeeds new contacts/glasses””..

Always record a patientAlways record a patient’’s complaint in their s complaint in their words. words.

Example: Blurred vision, eye pain, vision distortionExample: Blurred vision, eye pain, vision distortion

Appointments should also be classified by Appointments should also be classified by type of servicetype of service

Comprehensive examination Comprehensive examination –– Not RVNot RV

Diagnosis Codes: ICDDiagnosis Codes: ICD--99--CMCM

Codes are either 3,4,or 5 digits. Codes are either 3,4,or 5 digits. 3 digit coding is very general3 digit coding is very general

373 = Inflammation of eyelids373 = Inflammation of eyelids

4 digit coding increasing specificity4 digit coding increasing specificity373.0 = 373.0 = BlepharititsBlepharitits

5 digit coding is very specific5 digit coding is very specific373.01 = 373.01 = UclerativeUclerative blepharitisblepharitis

Diagnosis Codes: ICDDiagnosis Codes: ICD--99--CMCMInfections and parasitic diseasesInfections and parasitic diseases

001001--139.8139.8NeoplasmsNeoplasms

140140--239.9239.9Endocrine, Nutritional, Metabolic, ImmunityEndocrine, Nutritional, Metabolic, Immunity

240240--279.9279.9Blood and Blood forming OrgansBlood and Blood forming Organs

280280--289.9289.9Mental DisordersMental Disorders

290290--319.9319.9Nervous System and Sense OrgansNervous System and Sense Organs

320320-- 389.9389.9Disorders of the eye and Disorders of the eye and adnexaadnexa

360360--379.9379.9Circulatory SystemCirculatory System

390390-- 459.9459.9Respiratory SystemRespiratory System

460460-- 519.9519.9Digestive SystemDigestive System

520520-- 579.9579.9

Genitourinary SystemGenitourinary System580580--629.9629.9

Complications of Pregnancy, Childbirth and Complications of Pregnancy, Childbirth and PuerperiumPuerperium

630630--679.9679.9Skin and Subcutaneous TissueSkin and Subcutaneous Tissue

680680--709.9709.9MuscloskeletalMuscloskeletal System and connective tissueSystem and connective tissue

710710--739.9739.9Congenital anomaliesCongenital anomalies

740740--759.9759.9Conditions in the Conditions in the perinatalperinatal periodperiod

760760--779.9779.9Symptoms, Signs and illSymptoms, Signs and ill--Defined ConditionsDefined Conditions

780780--799.9799.9Injury and PoisoningInjury and Poisoning

800800--999.9999.9

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ICDICD--9 V9 V-- CodesCodes

Classification is provided to deal with the occasions when Classification is provided to deal with the occasions when circumstances other than a disease or injury classifiable to circumstances other than a disease or injury classifiable to categories are recorded as categories are recorded as ““diagnosesdiagnoses”” or or ““problems.problems.””

When a person who is not sick encounters health services for a pWhen a person who is not sick encounters health services for a purposeurposeOrgan or tissue donorOrgan or tissue donorProphylactic vaccinationProphylactic vaccinationDiscuss a problem which is in itself not a problemDiscuss a problem which is in itself not a problem

V65.5 Normal ExamV65.5 Normal ExamWhen a person with a disease or injury encounters the health caWhen a person with a disease or injury encounters the health care re system for treatment of that disease or injurysystem for treatment of that disease or injury

Dialysis for renal diseaseDialysis for renal diseaseChemotherapy for malignancyChemotherapy for malignancy

When circumstances are present which influences the personWhen circumstances are present which influences the person’’s health s health status but is not itself a current illness or injury. status but is not itself a current illness or injury.

V43.1 V43.1 PseudophakiaPseudophakiaV67.51 Meds with Ocular toxicityV67.51 Meds with Ocular toxicity

ICDICD--9 E Codes9 E Codes

Classification system of environmental Classification system of environmental events, circumstances, and conditions as events, circumstances, and conditions as the case of injurythe case of injury

Must be used in addition the diagnosis codeMust be used in addition the diagnosis codeE800E800--E999.9E999.9

HCPCS Material VHCPCS Material V--CodesCodes

Are also used to describe products Are also used to describe products optometrists dispenseoptometrists dispense

V2020V2020--V2025 FramesV2025 FramesV2100V2100--V2499 Spectacle LensesV2499 Spectacle LensesV2500V2500--V2599 Contact LensesV2599 Contact LensesV2600V2600--V2615 Low Vision DevicesV2615 Low Vision DevicesV2623V2623--V2632 Surgical suppliesV2632 Surgical suppliesV2700V2700--V2799 Spectacle Lens upgradesV2799 Spectacle Lens upgrades

Claim SubmissionClaim Submission

CMS 1500 formCMS 1500 formPaper formPaper form

Mailed or faxed inMailed or faxed inMedicaid requires that it must be typed and cannot be foldedMedicaid requires that it must be typed and cannot be folded

Web submissionWeb submissionSpecific to a single payer usuallySpecific to a single payer usuallyNo special forms or accounts requiredNo special forms or accounts required

Electronic clearing houseElectronic clearing housescrubs, formats and submits claims in realscrubs, formats and submits claims in real--time to hundreds time to hundreds of insurance companies for payment. of insurance companies for payment.

Uses electronic Payer IDsUses electronic Payer IDs

Cataract and RefractionCataract and Refraction Foreign BodyForeign Body

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PunctalPunctal PlugsPlugs Routine Vision w/ SpectaclesRoutine Vision w/ Spectacles