Download Eye Care and Eyewear Coding and Billing

Eye Care Coding and Billing
John W. Lahr, O.D., FAAO
Coding-Who is Responsible? The Provider of the Service!
Current Procedural Terminology-CPT
New vs. Established
“A new patient is one that has not received any professional services from the physician or another
physician of the same specialty who belongs to the same group within the past three years.”
What Code Do I Use for Exams?-92xxx vs. 99xxx
92xx4-Comprehensive/Intermediate
CPT 2002 Definition: “… describes a general evaluation of the complete visual system. The comprehensive
services constitute a single service entity but need not be performed at one session. The service includes
history, general medical observation, external and ophthalmological examinations, gross visual fields and
basic sensorimotor examination. It often includes, as indicated, biomicroscopy, examination with
cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment
programs.”
92xx4-Comprehensive
“Intermediate and comprehensive ophthalmological services constitute integrated services in which
medical decision making cannot be separated from examining techniques used. Itemization of service
components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry
or motor evaluation is not applicable.”
92xx2-Intermediate
CPT 2002 Definition: “… describes an evaluation of a new or existing condition complicated with a new
diagnostic or management problem not necessarily related to the primary diagnosis, including history,
general medical observation, external ocular and adnexal examination and other diagnostic procedures as
indicated: may include the use of mydriasis for ophthalmoscopy.”
Initiation of diagnostic and treatment program includes the prescription of medication, and arranging for
special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and
radiological services.”
Evaluation/Management Codes
99xxx-Site of Service Specific
Levels of Service
Generally 3 to 5 levels per site
Seven Components:
Three key components
History
Examination
Medical decision-making
Three contributory components
Counseling (Not always needed)
Coordination of care (Not always needed)
Nature of presenting problem
Time-can be the key factor when …
“When counseling or coordination of care dominates (more than 50%) the physician/patient and/or family
encounter (face to face time…), then time may be considered the key or controlling factor to qualify for a
particular level of E/M service. This includes time spent with parties who have assumed responsibility for
the care of the patient or decision making whether or not they are family members. The extent of the
counseling and/or coordination of care must be documented in the medical record.”
Evaluation/Management Codes
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New patients require three of three at or above the level selected
Established patients require two of three at or above the level selected
Documentation Guidelines
Obtain a copy of the proposed guidelines and stay in touch
www.ama-assn.org
www.cms.gov
History
Problem Focused
Chief complaint; brief history of present illness or problem
Expanded Problem Focused
Chief complaint; brief history of present illness; problem pertinent system review
Detailed
Chief complaint; extended history of present illness; problem pertinent system review extended to include a
limited number of additional systems; pertinent past, family and/or social history directly related to the
patient’s problems
Comprehensive
Chief complaint; extended history of present illness; review of systems which is directly related to the
problem(s) identified in the history of present illness plus a review of all additional body systems; complete
past , family and social review
Body Organ Systems
Constitutional
Ears, nose, mouth & throat
Respiratory
Genitourinary
Skin
Psychiatric
Blood/lymphatic
History of Present Illness
Location
Severity
Timing
Modifying factors
History Documentation
Eyes
Cardiovascular
Gastrointestinal
Musculotoskeletal
Neurological
Endocrine
Allergic/immunology
Quality
Duration
Context
Associated signs and symptoms
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 (Established)
Examination
Problem Focused
A limited examination of the affected body area or organ system
Expanded Problem Focused
A limited examination of the affected body area or organ system and other symptomatic or related organ
system
Detailed
An extended examination of the affected body area(s) and other symptomatic or related organ system(s)
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Comprehensive
A general multi-system examination or complete examination of a single organ system
Documentation of Exam Elements
Visual acuity
Pupils and iris
Bulbar and palpebral Conjunctiva
Slit lamp exam cornea
Slit lamp exam-AC
Optic nerve
Neurological (Time/Place/Person)
Confrontation VF
Adnexa
Extra-ocular muscles
Slit lamp exam-lens
IOP
Posterior segment
Psychiatric: (Depression/Anxiety/Agitation)
Documentation of Exam Elements
 Problem focused exam (PFE)-1-5 elements
 Expanded problem focused exam (EPF)-minimum 6 elements
 Detailed exam (DE)-minimum 9 elements
 Comprehensive exam (CE)
Medical Decision Making-Three key areas determine the complexity of medical decision-making
 The number of possible diagnosis and/or the number of management options considered
 The amount or complexity of medical records, diagnostic tests and/or information that must be
obtained, reviewed and analyzed
 The risk of significant complications, morbidity and/or mortality, as well as co-morbidities,
associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or possible
management options
Straightforward-Most MDM not at this level
 Low Complexity-Minimal MDM-low risk
 Moderate Complexity
 High Complexity
When two or more codes may be appropriate for an encounter, there is nothing wrong with selecting the
higher reimbursing code! As long as you are consistent!
Special Ophthalmological Services
Refraction-92015
 Not a component of intermediate, comprehensive or E/M office services
 Is a non-covered service by Medicare
 Should be billed as a separate line item
Other Specialized Services
92020-Gonioscopy
92081-Visual Field
92082-Visual Field
92083-Visual Field
92100-Serial Tonometry
Must use multiple measurements (3 minimum) to qualify
Other Specialized Services
92135-Scanning computerized imaging w/ interpretation and report
Bundled with 92250
Not truly indicated in advanced disease
92225-Ophthalmoscopy extended, with retinal drawing, interpretation and report, initial
92226-Ophthalmoscopy, subsequent …
Other Specialized Services
92250-Fundus photography w/ interpretation and report
92283-Color vision examination, extended
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92285-External ocular photography w/ interpretation and report for documentation of medical progress-
Know Utilization Patterns-Medicare-2004
92020-.3%
92135-2%
92225-12%
9208x-9%
92250-5%
76519-8%
Ocular Surgical Procedures
65205-Removal of foreign body, external eye; conjunctival superficial
65210-Removal of FB …conjunctival embedded (includes concretions)…
65220-Removal of FB … corneal w/o slit lamp
65222-Removal of FB …corneal w/ slit lamp
Ocular Surgical Procedures
65430-Scraping of cornea, diagnostic, for smear and/or culture
65435-Removal of corneal epithelium …(abrasion, currettage)
65600-Multiple punctures of anterior cornea (eg. For corneal erosion, tattoo)
Ocular Surgical Procedures
67820-Correction of trichiasis; epilation, by forceps only
68801-Dilation of lacrimal punctum, with or without irrigation
68761-Punctal occlusion by plug
76519-Ophthalmic biometry … A-scan w/ IOL power calculation
Punctal Occlusion Changes
68761-Includes cost of material (collagen or silicone) per plug
Decreasing fee per plug per procedure day
100% for first plug
50% for second plug
25% for remaining plugs
Needs use of modifier to designate position of plug-(E1-upper left, E2-lower left, E3 upper right,
E4 lower right)
Global period-10 days
Miscellaneous Procedures
New Category 1 Code-Pachymetry
CPT 76514
Can be billed now and most Medicare carriers have accepted
RVU-new in 2004-.33 or $12.32 (Glaucoma/IOP is a once in a lifetime billing)
Other diagnosis that drives payment:
 Corneal edema
 Cornea dystrophy
 Keratoconus
S-Codes
New HCPCS Codes-How to Use
Medicare and other Federal Payers do not recognize S-codes
May be useful for private payers or self pay patients when no other option available
 S0500-Disposable CL-per lens
 S0512-Daily wear specialty CL-per lens
 S0514-Color CL-per lens
 S0592-Comprehensive CL evaluation
 S0581-Non-standard lens (list in addition to standard lens code)
 S0580-Polycarbonate lens (list in addition to standard lens code)
 S0620-Routine comprehensive ophthalmological exam including refraction-new patient
 S0621-Routine comprehensive ophthalmological exam including refraction-established patient
 S0830-Ultrasound pachymetry-with interpretation and report
 S0800-LASIK
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S0810-PRK
S0812-PTK
S0820-Computerized Corneal Topography
Co-management
Co-management
 Major surgical procedure fees are 80% intra-operative and 20% post-operative
 The 20% post-operative fee is divided into 1/90th per day of care responsibility
 No restrictions exist with respect to what surgical procedures can be co-managed
 Many optometrists co-manage cataract and refractive surgical cases
 Glaucoma, retinal, plastic surgical and others are also eligible (Think outside the box)
To bill you need:
 Procedure code billed by surgeon
 Use surgical date for billing date
 Indicate dates of care responsibility
 Surgeon UPIN number
Modifiers
Can use –xx or 099xx
-21-Prolonged E/M Service
-22-Unusual Procedural Services
-24-Unrelated E/M Services by the Same Physician during a Post-op Period
-25-Significant, Separate Identifiable E/M Service by the Same Physician on the Same Day of Procedure or
Other Service
-26-Professional Component
Certain procedures are split into professional (evaluation) and technical (procedure testing)
components
-TC-Technical Component
-32-Mandated Services
Required by third party
-50-Bilateral Procedure
Used for codes that are designated unilateral and both eyes receive procedure on same day
-51-Multiple Procedures
Procedures other than E/M on same day
-52-Reduced Services
Multiple uses/often used
-53-Discontinued Procedure
-54-Surgical Care Only
-55-Post-operative Care
-56-Pre-operative Care
-57-Decision for Surgery
-76-Repeat Procedure by Same Physician
-77-Repeat Procedure by Another Physician
-99-Multiple Modifiers
List –99 first then other appropriate modifiers
E1-Upper left eyelid
E2-Lower left eyelid
E3-Upper right eyelid
E4-Lower right eyelid
RT-right eye
LT-left eye
QB-Physician services in a rural HSPA
QU-Physician services in urban HSPA
ZX-Tints, AR or UV prescribed by physician as medically necessary
GZ-Determination of baseline condition
GA-Waiver of liability statement on file
Indicates patient has signed an Advance Beneficiary Notice (ABN) for services or materials that may be
denied by Medicare. Notice must be retained in medical record
Diagnosis Codes-International Classification of Diseases (ICD)
 Use most detailed and specific code(s) possible for each submission
 List all pertinent diagnosis for each patient for most claims
 Some medical plans reject refractive diagnosis
 Some vision plans reject medical diagnosis
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 Avoid xxx.9 codes (garbage codes) whenever possible
List primary diagnosis first and others after
Diagnosis Codes
Detailed diagnosis coding:
Vitreous Degeneration for example
379.2-Disorders of vitreous body
379.21-Vitreous degeneration
379.9-Unspecified disorder of the eye and adnexa (most detailed and specific)
V-Diagnosis Codes
V42.5-Corneal transplant
V43.1-Pseudophakia
V58.69-Encounter-long-term (current use) of other (high risk) medications
V65.5-Person with feared complaint in whom no diagnosis was made
V67.51-Follow-up exam following completed treatment with high risk medication
V71.8-Observation and evaluation for other specified suspected conditions
V72.0-Special examination of eyes and vision
V80.1-Special screening for glaucoma
V80.2-Special screening for other eye conditions
Material Codes-Health Care Procedures Coding System (HCPCS)
V-Material Codes
V2020-Frames
V2025-Deluxe frame
V2100-2199-Single vision lenses
V2200-2299-Bifocal lenses
V2300-2399-Trifocal lenses
V2410-2499-Variable sphericity lenses
V2700-2799-Spectacle lens extras (All codes represent single lenses-bill 2 for pair)
V2500-2599-Contact lens materials
V2600-2615-Low vision aids
V2623-2632-Prosthetic eyes (includes IOLs)
A4262-Temporary, absorbable lacrimal duct implant, each (not reimbursed by Medicare)
A4263-Permanent, long term, no-dissolvable lacrimal duct plug, each (not reimbursed by Medicare)
A4214-4550-Surgical supplies
 Billing sent to Durable Medical Equipment Regional Carriers (DMERC)
 Send only materials claims to this Carrier not procedure codes
 Reimbursement rates vary for state to state within the DMERC regions
Medicare-The “Big” Payer
Medicare covered patients:
$124/year deductible
20% co-payment on Medicare approved fee amounts for services and materials
Must attempt to collect co-payment and deductible
Eyewear and contact lens materials covered only after cataract surgery
Aphakia-eyewear and contact lenses funded for life (within Medicare guidelines)
Pseudophakia-one benefit per eye/per lifetime
Who is eligible for Medicare benefits?
 Attained age of 65
 Under 65 w/ permanent kidney failure
 Under 65 and receiving social security disability for two years
PINs, UPINs and other numbers
Surrogate UPINs
VAD000-VA physicians w/o UPIN
PHS000-Public Health physicians w/o UPIN
RET000-Retired physicians never w/ UPIN OTH000-Providers not yet issued UPIN
PINs, UPINs and other numbers
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Each physician needs DMERC supplier number
Need DMERC number for each location
Re-enrollment very three years
Referring/ordering physician UPIN number must be on claim form of provider submitting for
services
Finding UPIN numbers for physicians
www.cpg.mcw.edu/www/upin.html
Fraud-intentional false representation to obtain benefits
 Billing for services not rendered
 Submitting invalid diagnosis
 Billing non-covered services as covered services
Abuse
 Exceeding “Limiting Charge” (Non-PAR)
 Fragmenting or Un-bundling services
 Routine waiver of deductible or co-insurance
 Breaches of the assignment agreement
Making Medicare Easier
 Make a copy of the current card and keep in file (front and back)
 Always discard previous copies and keep only current copy
 Gathering patient information
 Signature on file
 Pre-visit forms
 General information
 Clinical information
Use of routing slips
Timely submission of claims
Services within 15 months
Materials within 18 months
Claims and collection
 Electronic submission is the only way to go (You may be penalized in the future for paper claims)
 Electronic EOMB and payment-13 days
 Paper EOMB and payment-27 days
Collect from the Medicare patient at the time of the visit
 Only one question to ask the patient: “Have you met your Medicare deductible for the year?”
 Only one answer keeps you from assuming the patient has met the deductible: “YES”
 If any other answer follow the Medicare payment sheet
Advance Beneficiary Notice (ABN)
 Issued October 1, 2002
 Used for services and materials
 Not required for items excluded by statue, such as refraction, contact lenses not covered and
eyeglasses not covered
 Mandated as part of HIPAA
 Submit claims with -GA modifier
Copy to patient and one in the record
If form is not used, you are to provide a refund to the patient for amount collected
Form to include:
Patient name
Patient Medicare number
Proposed items or services
Reason denial is expected
An estimated cost field is optional
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Rejected Claims-Handle as soon as possible!
Determine reason for rejection
1. Unclean claim
a. Re-submit with revisions
2. Uncovered service
a. Bill patient
3. Unauthorized provider
a. Eat the charge as this is out of scope of services
4. Discrimination
a. Go after the plan
Discrimination
 Document the name of person on call
 Ask to speak to supervisor if the answer is not correct or appropriate
 Request reason be put in writing and sent
 Know the law and your rights
 Contact state association third party committee if not resolved personally
 Be persistent!
Resources
 AOA-Codes for Optometry-800-365-2219
 Primary Eye Care Network-800-444-9230
 www.cms.gov
 St. Anthony Publications-800-765-6588
o www.ingenix.com
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