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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 1 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) 2 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 3 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 4 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 5 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 6 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 7 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 8