Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Rebecca H. Wartman OD Heart of America Contact Lens Society 2015 Disclaimers for Presentation 1. All information was current at time it was prepared 2. Drawn from national policies, with links included in the presentation for your use 3. Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations 4. Prepared and presented carefully to ensure the information is accurate, current and relevant 5. No conflicts of interest exist for the presenterfinancial or otherwise Disclaimers for Presentation 6. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services 7. AOA, AOA-TPC, HOACLS, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein Coding BasicsDon’t Fall Asleep Coding Systems CPT ® Procedure Codes What You Do ICD-9-CM/ICD-10-CM Diagnosis Codes What You Find HCPCS Codes What You Supply (sometimes what you do) Modifiers What is Different Supply of Ophthalmic Materials Medicare/Medicaid and Other Carriers HCPCS Codes V2020 – V2799 (materials) HCPCS Codes S series Some services and material (S0500-S0625) Note not all are ophthalmic codes Contact Lens and Spectacle Services/materials Ocular Prosthetics New Patient Defined New patient Established patient New vs Established New patient: No professional services from the physician/qualified health care professional (QHP) or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within past 3 years Established patient: Professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspecialty who belongs to the same group practice within past 3 years Procedure Codes Eye Health & Well Vision Services 92000 Series General Ophthalmological Services 99000 Series Evaluation and Management (E&M) Services S-Codes 99000 Preventative Medicine Services CPT Definitions • HIPAA requires all providers and insurers to use CPT codes and definitions for describing services provided to patients • CPT copyright requires anyone who uses the codes to comply with the definitions for the codes • Choosing codes by matching the content of the record to the CPT definition provides effective support in the case of a payer audit Evaluation and Management (E & M) • 1995 or 1997 guidelines for E&M codes • 1997 simpler, have to specify in audit • Presenting 1997 guidelines from CPT® • 99--- codes • Office • Hospital • Nursing facility • Domiciliary/rest home • Home Medicare no longer covers consultations E & M Overview-1995 vs 1997 E/M Components History 1995 1997 History of the Present Illness (HPI) Description of the elements (e.g., location, quality, severity) Descriptions of the elements (e.g., location, quality, severity, etc.) or status of three chronic/inactive diseases Review of Systems (ROS) No difference No difference Past, Family and Social (PFSH) No difference No difference Examination Medical Decision Making General multi-system or single Body areas, organ organ system (e.g., systems or complete cardiovascular, eyes, psychiatric, single organ system etc.) No difference No difference Elements of E & M Codes Major elements • Chief Complaint – Always • History • Examination • Medical decision-making Other factors considered • Counseling • Coordination of care • Nature of presenting problem • Time Elements of E & M Codes • Chief Complaint • Always, every encounter • Concise statement describing • • • • • • Symptom Problem Condition Diagnosis Physician recommended return Any other factor related to reason for the encounter • Usually stated in the patient's words Elements of E & M Codes History of present illness 8 elements 2 levels Review of systems 14 elements 3 levels Past, family, social history 3 elements 2 levels History of Present Illness Chronological description of development of present illness from: • First sign and/or symptom • Previous encounter to present History of Present Illness Elements • • • • • • • • Location 1997 documentation guidelines Quality Descriptions of the elements (e.g., Severity location, quality, severity, etc.) Duration or Timing status of three chronic/inactive diseases. Context Modifying factors Associated sign & symptoms Levels Brief: 1-3 elements Extended: 4+ elements Review of Systems An inventory of body systems obtained via questions to identify signs/symptoms that patient may be experiencing or has experienced Constitutional Musculoskeletal Eyes Integumentary Ears, nose, throat (E/N/T) Neurological Cardiovascular Psychiatric Respiratory Endocrine Gastrointestinal Genitourinary Hematologic/Lymphatic Allergic/Immunologic Review of Systems Problem oriented: • +/- system related to problem Extended problem oriented: • +/- 2-9 systems Complete: • +/- 10 or more systems Review of Systems • Individually document all positives • Individually document all negatives • Up to the number of elements required for level • Then may indicate all other systems negative BUT • Avoid saying “all 10 systems negative” Past, Family, Social History Past history Family history Social history Past, Family, Social History • Pertinent: • One in any of the three areas • Complete: • One in all three areas for new • Two of three for established Overall History Components Comprehensive Detailed Problem focused Expanded problem focused Overall History Components Problem focused HPI: Brief (1-3 elements) ROS: Not applicable PFS: Not applicable Expanded problem focused HPI: Brief (1-3 elements) ROS: Problem oriented (1 specific system) PFS: Not applicable Overall History Components Detailed HPI: Extended(4+ elements) ROS: Extended (2-9 elements) PFS: Pertinent(1/3 elements) Comprehensive HPI: Extended (4+ elements) ROS: Complete (10 elements) PFS: Comprehensive (3/3 NP or 2/3 EP) History Summary Table Type of History History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) Problem Focused Brief N/A N/A Expanded Problem Focused Brief Problem Pertinent N/A Detailed Extended Extended Pertinent Comprehensive Extended Complete Complete Examination Elements 4 Levels (1997) Problem focused Expanded problem focused Detailed Comprehensive Examination Elements Single System 14 elements Visual Acuity Confrontation Field EOM/Alignment Conjunctiva SLE – cornea/tears SLE – anterior chamber SLE - Lens Adnexa/lacrimal DFE – Optic nerve DFE – Posterior seg Pupils/iris Orientation IOP Mood/affect Examination Elements Single System • • • • • Visual acuity (Does not include refraction) Gross visual field testing by confrontation Ocular motility include primary gaze alignment Inspection of bulbar/palpebral conjunctivae Examination of • Ocular adnexae including lids (eg, ptosis or lagophthalmos), Lacrimal glands, lacrimal drainage, orbits Preauricular lymph nodes Examination of pupils/irises Shape Direct and consensual reaction (afferent pupil) Size (eg, anisocoria) Morphology Examination Elements Single System • Slit lamp examination Corneas Anterior chambers Crystalline lens Measurement of intraocular pressures Image courtesy Topcon Examination Elements Single System • Dilated fundus examination • Ophthalmoscopic examination Optic discs Posterior segments PLUS - Orientation to time place person AND Indirect ophthalmoscope - Mood and affect (eg, depression, anxiety, agitation) Examination Elements Single System • Problem oriented 1-5 elements • Expanded problem oriented 6 elements • Detailed 9 elements • Comprehensive 14 elements* * all elements plus one Mood or orientation Medical Decision Making Number of possible diagnoses Amount- complexity of medical records, diagnostic tests, and/or other information Risk of significant complications, morbidity and/or mortality Comorbidities Medical Decision Making Other secondary factors to consider • • • • Counseling Coordination of care Nature of presenting problem Time Time is key only when counseling and care coordination are the primary component (more than 50% of time spent with patient) Medical Decision Making Straightforward/Minimal • One presenting problem • Simple diagnostic procedures • Simple management options- comfort measures Medical Decision Making Low Two or more self-limiting or minor One stable chronic Acute, uncomplicated illness • More complicated diagnostic procedures • Management options: OTC meds, PT Medical Decision Making Moderate 1+chronic with exacerbation/2+ stable chronic Undiagnosed new problem Acute with systemic sx Acute complicated injury • More complicated Diagnostic procedures Higher Risk • Management options Rx meds Minor surgery Medical Decision Making High 1+chronic/severe exacerbation Acute/chronic illness with risk Abrupt neurologic status change • Extremely complicated diagnostic procedures • Management options Major surgery IV medications DNR decision Medical Decision Making The highest level of risk in any of the three determines overall risk • Presenting problems(s) • Diagnostic procedures • Management options Medical Decision Making Document • Findings • Visualizations • Plans • Test results • Consultations • Old record requests In short DOCUMENT EVERYTHING!! Elements of 99--- Codes Code History Exam Decision 99201 Problem Focused Problem Focused Straightforward 99211 Staff only NA No Doctor NA Abuse potential NA Per CMS 99202 Expand Problem Focused Expand Problem Focused Straightforward 99212 Problem Focused Problem Focused Straightforward 99203 Detailed Detailed Low 99213 Expand Problem Focused Expand Problem Focused Low Elements of 99--- Codes Code History Exam Decision 99204 Comp Comp Moderate 99214 Detailed Detailed Moderate 99205 Comp Comp High 99215 Comp Comp High CPT Examples for Eye Care New Patients 99201 Initial office visit for a 10-year-old girl for determination of visual acuity as part of a summer camp physical (does not include determination of refractive error) 99203 Initial office visit for a 55-year-old female with chronic blepharitis. There is a history of use of many medications 99205 Initial office visit for a 70-year-old diabetic patient with progressive visual field loss, advanced optic disc cupping and neovascularization of retina CPT Examples for Eye Care Est. Patients 99213 Office visit for a 65-year-old female, established patient, with primary glaucoma for interval determination of intraocular pressure and possible adjustment of medication 99214 Office visit for a 68-year-old male, established patient, with the sudden onset of multiple flashes and floaters in the right eye due to a posterior vitreous detachment General Ophthalmologic Services C O D E S 92002 92012 92004 92014 General Ophthalmologic Services CPT ® Codes Note: Current Procedural Terminology(© American Medical Association) is the only accepted source of definitions for these services. 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient 92004 ;comprehensive, new patient, 1 or more visits General Ophthalmologic Services CPT ® Codes 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient 92014 ;comprehensive, established patient, 1 or more visits General Ophthalmologic Services CPT® Definition Comprehensive Ophthalmological Services Comprehensive ophthalmological services 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 ophthalmoscopic 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. General Ophthalmologic Services 92004 & 92014 Introduction in CPT ® General evaluation of the complete visual system (1 or more sessions) Includes: • • • • • • History General medical observation External examination Ophthalmoscopic examination Gross visual fields Basic sensorimotor examination Often includes: • Biomicroscopy • Examination with cycloplegia or mydriasis • Tonometry Always includes: Initiation/continuation of diagnostic and treatment programs General Ophthalmologic Services CPT® Definition Intermediate Ophthalmological Services Intermediate ophthalmological services describes an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating 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. General Ophthalmologic Services 92002 and 92012 Introduction in CPT® Evaluation of new/existing condition complicated by new diagnostic/management problem not necessarily related to primary diagnosis Includes History General medical observation External examination Adnexal examination May Include Other diagnostic procedures Mydriasis of ophthalmoscopy Always includes Initiation/continuation of diagnostic and treatment programs General Ophthalmologic Services Diagnostic and Treatment Program Includes, but not complete list: • Prescription of medication • Special ophthalmological diagnostic/treatment services • Consultations • Laboratory procedures • Radiological services General Ophthalmologic Services May also include!! None of these special tests have individual CPT codes but are included in intermediate and/or comprehensive general ophthalmologic examinations 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Laser interferometry Potential acuity meter Keratometry Exophthalmometry Transillumination Corneal sensation Tear film adequacy Phacometry Schirmer’s test Slit lamp History General medical observation General Ophthalmologic Services How Intermediate & Comprehensive Ophthalmological Services differ from E&M : Medical decision making cannot be separated from examining techniques Itemization of service components is not applicable • Slit lamp examination • Keratometry • Routine ophthalmoscopy • Retinoscopy • Tonometry • Motor evaluation General Ophthalmologic vs E&M Codes? What is the difference? General ophthalmologic services • Intermediate and comprehensive • Do not require three key components o History o Examination o Medical decision-making • Do not use E&M documentation guidelines from CMS to determine proper code selection General Ophthalmologic vs E&M Codes? • No mandated use of one code set over other • Report code(s) most accurately identifies service(s) or procedure(s) performed • General ophthalmological service codes are specific for services typical of ophthalmological visit Note that some carriers state: Services that require minimal ophthalmologic examination techniques are reported with the E/M CPT codes (99201 through 99499) General Ophthalmologic Services Example of Comprehensive Services From CPT® The comprehensive services required for diagnosis and treatment of a patient with symptoms indicating possible disease of the visual system, such as glaucoma, cataract or retinal disease, or to rule out disease of the visual system. General Ophthalmologic Services Examples of Intermediate Examination From CPT® • Acute complicated condition (eg, iritis) not requiring comprehensive ophthalmological service • Review of history • External examination • Ophthalmoscopy • Biomicroscopy General Ophthalmologic Services Examples of Intermediate Services From CPT® • Established patient with known cataract not requiring comprehensive ophthalmological services • Review of interval history • External examination • Ophthalmoscopy • Biomicroscopy • Tonometry General Ophthalmologic Services Coding Guidelines • Chief Complaint- Reason for visit • Still necessary • Documentation • To establish medical necessity • General medical observations • Require dilation for 92004/92014(NOT per CPT, carrier specific?) • Must include initiation/continuation of diagnostic and treatment programs General Ophthalmologic Services Summary • General ophthalmologic code set requirements is more straight forward than E&M code set requirements • Do NOT include refraction • Some carriers have specific definitions for intermediate and comprehensive levels apparently beyond what CPT® states IMPORTANT: Initiation of diagnostic & treatment program seems to be the most audited item by Medicare Routine examination codes (HCPCS Codes) S0620 – Routine ophthalmologic/NP S0621 – Routine ophthalmologic/EP Both includes refraction Becoming more common Some Medicaid now using Optional/required for many vision plans AOA strongly discouraging insurer use No valuation so problematic 92000 Codes Special Ophthalmological Services Describe services for special evaluation of part of visual system goes beyond General Ophthalmic Services, or special treatment is given Special ophthalmological services may be reported in addition to the general ophthalmological services or E&M Interpretation and report by physician or QHP is integral part of special ophthalmological services where indicated 92000 Codes Special Ophthalmological Services 92015 to 92140 Refraction Contact Lens and Spectacle Services Extended Ophthalmoscopy Fundus Photography Scanning Laser Technology Color Vision Examination Gonioscopy External Ocular Photography Sensorimotor Evaluation Visual Fields Modifiers Used to report service or procedure performed Altered but not changed in definition or code Service/procedure with professional & technical component Service/procedure performed by >1 OD &/or in >1 location Service/procedure increased or reduced Part of service performed Adjunctive service performed Bilateral procedure performed Service/procedure provided more than once Unusual events occurred Modifiers ►Procedures 22: Increased procedural services-Not E&M 50: Bilateral procedures 51: Multiple procedures 52: Reduced services 53: Discontinued procedure-extenuating conditions 55: Postoperative management only 59: Distinct Procedural Services-Not E&M 76: Repeat procedure by the same physician 77: Repeat procedure by another physician 79: Unrelated procedure during postop Modifiers ►E&M Services 25: Significant, Separately Identifiable E&M service, same physician, same day of procedure/other service 24: Unrelated E&M during postop 26: Professional component RT: Right eye LT: Left eye E1: Upper left lid E2: Lower left lid E3: Upper right lid E4: Lower right lid TC: Tech component GW: Hospice pt Modifier 59 New CMS Guidance XE – Separate encounter Service is distinct because it occurred during separate on same date of service XS – Separate Structure Service is distinct because it was performed on a separate organ/structure XP – Separate Practitioner Service is distinct because it was performed by different practitioner XU – Unusual Non-Overlapping Service Service is distinct because it does not overlap usual components of the main service Should be used in lieu of modifier 59 when possible Modifier 59 should only be utilized if no other more specific modifier is appropriate NCCI Edits- 59 Modifier Manual “Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site” Medicare replacing 59 modifer with new codes-2015 NCCI Edits- 59 Modifier Manual 1. 2. 3. 4. 5. 6. Two procedure codes together if performed at different anatomic sites or different patient encounters Should NOT be used to bypass an NCCI edit unless proper criteria for use of -59 modifier is met Does not require a different diagnosis Different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ And treatment of posterior segment structures in eye constitute a single anatomic site Modifier 59 New CMS Guidance Page 2, NCCI Modifier 59 Article Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site. (See example 5) Example 5: 67210/67220 67210 – Destruction of localized lesion of retina (eg, macular edema, tumors),…; photocoagulation 67220 – Destruction of localized lesion of choroid (eg, choroidal neovascularization),…; photocoagulation 67220 should not be reported Modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ National Correct Coding Initiative Edits (NCCI) 92133 and 92134 ALWAYS mutually exclusive 92133 and 92250 AND 92134 and 92250 Generally considered mutually exclusive Provider would use one technique or the other Some exception where can use -59 modifier If both techniques are medically reasonable/necessary on ipsilateral eye 59 modifier: distinct or independent from other services performed on the same day BUT….. NCCI Edits Manual Chapter XI,p234 “Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (e.g., CPT codes 92132, 92133, 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250” NO EXAMPLES GIVEN! Fundus Photography and Scanning Laser CPT Assistant November 2014 page 10 “If the scanner produces an image of the retina or optic nerve along with other data and imaging for quantitative analysis, it would be appropriate to report a single service from the appropriate scanning computerized ophthalmic diagnostic imaging code range (92133-92134) If only an image is obtained, then code 92250 would be reported” “…if the only necessary service provided is generating a fundus photograph without the need to quantify the nerve fiber layer thickness and to analyze the data via a computer, then reporting code 92250 is appropriate, even if the photograph was taken with a scanning laser.” Modifier 25 Significant, Separately Identifiable E&M service, same physician, same day of procedure/other service Best example: Established patient If trichiasis incidental to E&M ► bill E&M with -25 modifier If reason for visit- ONLY bill epilation New patient Should not need -25 modifier if new patient with E&M Fitting of Therapeutic Contact Lens 92071 and 92072 (No LCD) 92071 Fitting of contact lens for treatment of ocular surface disease 92072 Fitting of contact lens for management of keratoconus, initial fitting (one time only) Do not report 92071 and 92072 together Note: Supply of lens is not included in either code Use 99070* or HCPCS V code to report supply Issues with payment on supply Best to use ABN and tell patient not covered 92071 NCCI Edits Manual Chapter XI,p 234 CPT code 92071 Fitting of contact lens for treatment of ocular surface disease Should not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea. QUESTIONS? THANK YOU!!