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Welcome to CODEquest 2008! Congratulations to all who have passed the Ophthalmic Coding Specialist Exam CODEquest – Financial Disclosure Ms. Vicchrilli does not have any financial interest or relationships to disclose. CODEquest Topics In the following patient examples, we will cover: • E&M vs. Eye codes • Consultations • Special testing CODEquest Topics • Modifier application • Minor procedures for each specialty • Major surgical procedures for each specialty; and CODEquest Topics • Answer the really tough questions. CODEquest Topics • Billing for the interim exam between cataract surgeries • Billing for an injection and an exam the same day • Billing for OCT and fundus photography on the same day CODEquest Topics • Coding for new corneal procedures CODEquest Topics • There will also be staff meetings. Agenda 1. What’s new in 2008 2. Ethics 3. EOMB errors CODEquest Topics • Tips from the most effective offices. What’s New in 2008 • Medicare Part B deductible increases to $135 compared to $131 in 2007. 2008 CPT Update Initial Nursing Facility Care Change of description 99304 Physicians typically spend 25 minutes with the patient and/or family or caregiver 99305 35 minutes 99306 45 minutes 2008 CPT Update Subsequent Nursing Facility Care Change of description 99307 Physicians typically spend 10 minutes with the patient and/or family or caregiver. 99308 15 minutes 99309 25 minutes 99310 35 minutes 2008 CPT Update • CPT code 67038 Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping – will be deleted and replaced with three new codes 2008 CPT Update 67041 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) 67041 CCI edits: 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 65800, 65805, 65810, 65815, 66830, 66840, 66852, 66920, 66930, 66940, 67005, 67010, 67015, 67025, 67027, 67028, 67036, 67101, 67105. 67107, 67110, 67112, 67120, 67121, 67141, 67145, 67500, 67515, 68200, 90760, 90765, 90772, 90774, 90775. Mutually exclusive 69990 67041 RVUs: 30.23 no site-of-service differential Global period: 90 days Assistant-at-surgery: yes 2008 CPT Update 67042 with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) 67042 CCI edits: 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 67036, 67108, 67110, 67112, 67500, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 67042 RVUs: 34.62 no site-of-service differential Global period: 90 days Assistant-at-surgery: yes 2008 CPT Update 67043 with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation 67043 CCI edits: 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 67036, 67107, 67108, 67110, 67112, 67113, 67500, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 67043 RVUs: 36.33 Global period: 90 days Assistant-at-surgery: yes 2008 CPT Update 67113 Repair complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser phtoocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens 67113 CCI edits: G0186, 36000, 36410, 37202, 62318, 62319, 64400, 64402, 64405, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66985, 66986, 67005, 67010, 67015, 67025, 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67101, 67105, 67107, 67108, 67110, 67112, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 67500, 67515, 68200, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 67113 RVUs: 39.88 Global period: 90 day Assistant-at-surgery: yes 2008 CPT Update 67229 Treatment of extensive or progressive retinopathy, one or more sessions; preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathyof prematurity), photocoagulation or cryotherapy 67229 CCI edits: 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 67500, 67515, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 67229 RVUs: 26.23 Global period: 90 day Assistant-at-surgery: no CPT Update Change of description - ? 67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions, cryotherapy, diathermy Old language 67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; cryotherapy, diathermy CPT Update Change of description 67228 Treatment of extensive or progressive retinopathy, one or more sessions; (eg, diabetic retinopathy), photocoagulation Old language Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) CPT Update • 68816 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation 68816 CCI edits: 36000, 36410, 67202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 67500, 68810, 68811, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 68816 RVUs: 15.91/5.67 Global period: 10 day Assistant-at-surgery: no CPT Update Change of description 92135 Scanning computerized ophthalmic diagnostic imaging, posterior segment, (eg, scanning laser) with interpretation and report, unilateral CPT Update Category III code: 0187T Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral No RVUs – until a local policy developed, patient is responsible for payment New PhotoScreening Code • 99174 Ocular photoscreening with interpretation and report, bilateral – (Do not report 99174 in conjunction with 92002-92014, 99172, 99173) • Deleted 0065T to create new Category 1 code for photoscreening • Not valued by the RUC HCPCS Update • Lucentis received a HCPCS code November 5th • J2778, ranibizumab injection 0.1mg effective January 1, 2008. Put 5 in the unit field ASC Update • Effective January 1, 2008 all surgical procedures will be ASC approved, with the exception of - codes that contain the description of “with hospitalization” - procedures that require an over-night hospital stay Office of the Inspector General • To promote integrity, economy, efficiency and effectiveness within all HHS programs • Chief audit and law enforcement executive for the entire Department, including the Centers for Medicare & Medicaid Services. 2008 OIG Work Plan • Place of Service Errors – Because different settings pay at different rates OIG wants to ensure accurate reporting of setting • E&M Services During Global Surgery Periods – Investigation as to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee 2008 OIG Work Plan • Medicare Payments for Selected Physician Services – Very few details except that they will review appropriateness of billing for physician services • Medicare “incident-to” Services – Will review medical necessity, quality of care and documentation for these services 2008 OIG Work Plan • Assignment Rules by Medicare Providers – Providers can’t balance bill beneficiaries for amounts in excess of the Medicare allowable • Geographic Areas with High Utilization of Ultrasound Services – Examine disproportionately high Medicare allowed charges and services per beneficiary -codes affecting ophthalmology are: – 76510, 76511, 76512, 76513, 76514, 76516, 76519, 76529 Questions? CIGNA LCDs Blepharoplasty December 2005 Botulinum Toxin January 2007 Cataract Extraction Preoperative Evaluation Computer Corneal Topography Extended Ophthalmoscopy Fundus Photography November 2004 November 2006 July 2007 November 2007 CIGNA LCDs General Ophthalmological September 2007 Services Removal Benign Skin Lesion November 2007 SLGT November 2007 Visual Field YAG November 2007 May 2007 • When you accept payment from a third party payer, each will have its own policies to follow: - Medicare - Non-Medicare or commercial payers - Medicaid E&M vs. Eye Codes - Review requirements for E&M - Review requirements for Eye codes E&M vs. Eye Codes 99201 1.03 99202 1.77 99203 2.54 99204 3.91 99205 4.94 92002 92004 1.83 3.43 99241 1.35 99242 2.52 99243 3.46 99244 5.11 99245 6.24 E&M vs. Eye codes 99211 0.5 99212 1.03 99213 1.71 99214 2.57 99215 3.46 92012 1.93 92014 2.82 • The first several patients of the day are established patients Patient #1 • Patient c/o bumps RUL, causing significant swelling x 2 days. Slight discharge in am. Blurred vision. Warm compresses some help Chief complaint Bumps Location Quality Duration Right upper lid Significant 2 days Associated signs Blurred vision Modifying factors Warm compresses help Patient #1 • Diagnosis chalazion (plural = chalazia) 373.2 • Excision is performed Patient #1 – Coding Options 67800 Excision chalazion; single Put 2 in the unit field 67800 Excision chalazion; single Append modifier 59 indicting two separate sites Excision chalazion; E3 or no modifier multiple, same lid 67801 Patient #1 99212 Established patient level 2 -25 67801 Excision of chalazion; No modifier multiple, same lid $38 $146 Patient #1 • Note: Some non-Medicare payers always bundled the exam with a minor procedure performed on the same day. Patient #2 • CC: FB sensation OS x early this am. +3 pain, photophobia. Pt building tool shed Chief complaint Foreign body Location Left eye Quality Duration +4 pain Early morning Photophobia Associated signs Modifying factors Working with wood/metal Patient #2 • Diagnosis 930.8 Foreign body • Removal is performed Patient #2 99213 92012 65222 Established patient level 3; or Intermediate exam -25 $62 -25 $64 Removal of foreign -LT body, external eye; corneal, with slit lamp $69 Patient #3 • P/O cataract OS x three weeks C/O decreased vision DX Cystoid macular edema Patient #3 • Is this a billable exam? • If referred to a retina specialist – is it a billable exam? - within the practice? - outside the practice? Patient #4 • P/O cataract OD 1 month. Vision not as good as it was previously. Presents today for glaucoma check OS • Exam revealed capsular haze OD, IOP check OS, YAG performed OD Patient #4 • Is this a billable visit? • Is documentation sufficient? • What modifiers should be appended? Patient #4 • Exam modifiers 24 and 57 • YAG modifier RT Patient #5 • CC: Progressive decreased vision OU x 3 months. OD worse. Difficulty performing any near work, sewing, reading Chief complaint Decreased vision Location Both eyes Quality Duration Progressive Three months Associated signs Right eye worse Modifying factors Problems seeing at near Patient #5 • Exam reveals bilateral cataracts. IOLMaster is ordered • Surgery scheduled for the right eye • Patient requests P-C IOL. NEMB is signed and specialized informed consent given Patient #5 99204 92004 92015 New patient, level 4; or -57 if surgery is $144 performed within 3 days Comprehensive -57 if surgery is $126 exam performed within 3 days Refraction N/A Determined by physician Patient #5 92136 92136 IOL Master payment -RT = the global technical component and the professional component of the right eye; or -TC -RT -26 -RT $86 $28 $58 Patient #5 V2788 -RT Determined Presbyopia-correcting function of an intraocular -GY?? by physician lens for the amount the patient pays out-ofpocket Patient #6 • Exam reveals bilateral cataracts. IOLMaster is ordered • Surgery scheduled for the right eye • Patient qualifies for toric IOL Patient #6 A9270 Non-covered item or service, for the amount the patient pays out-ofpocket -RT Determined by -GY?? physician Patient #5 and #6 • What if these patients need a YAG capsulotomy within the global period? • What if the patients request an IOL exchange? • Can we charge the patient out-ofpocket for these services? Patient #5 and #6 66821 Laser surgery -78 (eg, YAG laser) (one or more sessions) -RT $282 Payment will be 80% of the allowable. Don’t start a new global period 66986 Exchange of intraocular lens -78 -RT $808 Payment will be 80% of the allowable. Don’t start a new global period Patient #7 • This cataract patient is requesting monovision (one eye distance, one eye near) following cataract surgery. • Are there additional fees a physician can charge in this situation? Patient #8 • The patient is so pleased with the outcome of the right eye cataract surgery, that within the global period, surgery on the left eye is scheduled. • A brief exam is performed. Is this a billable exam? Questions? Ethics Stated here are the Principles and Rules of the Code Ethics that may come into play when assigning CPT codes for care provided to a patient. Ethics - Background The Principles of Ethics are aspirational and inspirational guidelines, and are not enforceable by the Academy’s Ethics Committee. The Rules of Ethics, on the other hand, are mandatory and prescriptive standards of minimally acceptable conduct and are enforceable by the Academy’s Ethics Committee. A determination of failure to observe the Code of Ethics will result in the Academy imposing appropriate sanctions. Principles of Ethics – Principle 5 • Fees for Ophthalmological Services. Fees for ophthalmological services must not exploit patients or others who pay for the services. Example – Principle 5 • A patient with AMD is seen for a routine exam. The patient has recently gotten a new job and now has a new health insurance provider. This provider is one which the physician knows is a prompt payer that seldom challenges claims. Example – Principle 5 • The physician orders a fluorescein angiography even though there is no documented change in the patient’s visual fields. • He states that the reason for the FA is to document the baseline for the new insurance company. He continues to order frequent FAs on a stable patient. Rules of Ethics – Rule 3 • Clinical Trials and Investigative Procedures. Use of clinical trials or investigative procedures shall be approved by adequate review mechanisms. Clinical trials and investigative procedures are those conducted to develop adequate information on which to base prognostic or therapeutic decisions or to determine etiology or pathogenesis, in circumstances in which insufficient information exists. Rules of Ethics – Rule 3 • Clinical Trials and Investigative Procedures. Appropriate informed consent for these procedures must recognize their special nature and ramifications. Rules of Ethics – Rule 3 • Dr. Z is a researcher in a clinical trial for an investigational corneal trephine. Patients enrolled in the clinical trial are provided care free-of-charge as part of the parameters of the funded trial. • Patient A volunteered for the clinical trial hoping to benefit from the new device; she has corneal dystrophy as well as diminished vision from nuclear-sclerotic cataracts. Rules of Ethics – Rule 3 • Dr. Z orders a series of tests performed on Patient A relating to her cataract rather than her corneal dystrophy. • Dr. Z knows these tests will be reimbursed even though Patient A is involved in the clinical trial solely for treatment with the investigational trephine. Rules of Ethics – Rule 3 • A doctor is testing a new IOL undergoing final clinical trials. He informs the patient that he will perform “routine cataract surgery” and expects that the patient will be delighted with the outcome. • The special nature of the IOL used is not revealed. The surgeon then submits a claim to Medicare for 66984, for which he will be reimbursed more than the manufacturer would pay for the surgery in the clinical trial. Rules of Ethics – Rule 6 • Pretreatment Assessment. Treatment shall be recommended only after a careful consideration of the patient's physical, social, emotional and occupational needs. The ophthalmologist must evaluate the patient and assure that the evaluation accurately documents the ophthalmic findings and the indications for treatment. Rules of Ethics – Rule 6 • Pretreatment Assessment. Recommendation of unnecessary treatment or withholding of necessary treatment is unethical. Rules of Ethics – Rule 6 • Dr. X performs cataract surgery on a patient with a pupil that dilates sufficiently to perform cataract surgery, but not as well as a routine case. • Dr. X uses iris retractors as a “precaution” and codes the higher-paying cataract surgery code, 66982. Rules of Ethics – Rule 7 • Delegation of Services. Delegation is the use of auxiliary health care personnel to provide eye care services for which the ophthalmologist is responsible. An ophthalmologist must not delegate to an auxiliary those aspects of eye care within the unique competence of the ophthalmologist (which do not include those permitted by law to be performed by auxiliaries). Rules of Ethics – Rule 7 When other aspects of eye care for which the ophthalmologist is responsible are delegated to an auxiliary, the auxiliary must be qualified and adequately supervised. An ophthalmologist may make different arrangements for the delegation of eye care in special circumstances, so long as the patient's welfare and rights are the primary considerations. Rules of Ethics – Rule 7 Dr. R performs a routine cataract surgery on Patient S, an elderly man who is showing signs of senile dementia. Dr. R’s technician obtains a signature on the consent form. An uneventful cataract surgery is performed. On the first postop day, Patient S is seen by an optometrist who routinely sees Dr. R’s postop patients. Optometrist Q notes in the patient’s chart that she is unable to visualize the fundus due to “blood in the globe.” Rules of Ethics – Rule 7 On postop day three, Patient S complains that his vision is distorted and the eye is painful. OptometristQ, again notes the presence of considerable blood obscuring adequate examination. The patient is put on analgesics and asked to return in two days. On postop day five, the patient complains of no vision and a very painful eye; Optometrist Q refers him to a retina specialist who diagnoses a total retinal detachment. Rules of Ethics – Rule 7 Reattachment surgery is performed to no avail; all useful vision is lost. Dr. R, the cataract surgeon, discovers this outcome and begins to “back code”, indicating that he performed all the postop care to avoid others learning that he delegated this patient’s care to an optometrist who, although licensed to perform the functions assigned to her, was not apparently competent to do so, resulting in the loss of the patient’s vision. Rules of Ethics – Rule 8 • Postoperative Care. The providing of postoperative eye care until the patient has recovered is integral to patient management. The operating ophthalmologist should provide those aspects of postoperative eye care within the unique competence of the ophthalmologist (which do not include those permitted by law to be performed by auxiliaries). Rules of Ethics – Rule 8 Otherwise, the operating ophthalmologist must make arrangements before surgery for referral of the patient to another ophthalmologist, with the patient's approval and that of the other ophthalmologist. Rules of Ethics – Rule 7 The operating ophthalmologist may make different arrangements for the provision of those aspects of postoperative eye care within the unique competence of the ophthalmologist in special circumstances, such as emergencies or when no ophthalmologist is available, so long as the patient's welfare and rights are the primary considerations. Fees should reflect postoperative eye care arrangements with advance disclosure to the patient. Rules of Ethics – Rule 7 A cataract surgeon performs an uncomplicated cataract surgery by referral from an optometrist. In the preoperative consent discussion, there is no discussion of postoperative care arrangements. On the first postoperative day, the surgeon states that the eye is “perfect” and that his job is done. Rules of Ethics – Rule 7 He codes 66984 with modifier 54 for the surgery and 99024 for the postop visit, and asks his secretary to schedule a visit with the referring optometrist in one week, whose office is 3 blocks away. Rules of Ethics – Rule 9 • Medical and Surgical Procedures. An ophthalmologist must not misrepresent the service that is performed or the charges made for that service. Rules of Ethics – Rule 9 • Dr T has performed a routine cataract extraction on Patient U. It is now the first day postop and Dr. T tells the patient that her eye “looks good,” but there’s some “haze to the capsule” so just to be on the “safe side,” he is going to schedule a YAG laser capsulotomy in 13 weeks to avoid “visual loss.” Rules of Ethics – Rule 9 The capsule opacity is inconsequential and asymptomatic. Nevertheless, the patient is made to understand that there is a serious but remediable problem, and gives consent for the procedure. Dr. T performs the YAG capsulotomy the day after the global period for the cataract surgery has passed, and submits a claim for the procedure. Rules of Ethics – Rule 9 Dr. W performs an exam on Patient V who presents with foreign body sensation of three days’ duration. Dr. W sees an eyelash floating on the surface of her cornea. Dr. W removes the eyelash and checks the patient’s other eye for the same reason. Dr. W tells Patient V that he did indeed find a foreign body and removed it. He quickly shows her the surface of a gauze pad on which the “foreign body” lies. Rules of Ethics – Rule 9 The patient cannot see the foreign body, but trusts Dr. W and now feels better. Dr. W instructs his staff to code the visit: 99213-25 65222 Level 3 established patient Removal of foreign body, external eye; corneal, with slit lamp $62 $69 Rules of Ethics – Rule 10 Procedures and Materials. Ophthalmologists should order only those laboratory procedures, optical devices or pharmacological agents that are in the best interest of the patient. Ordering unnecessary procedures or materials or withholding necessary procedures or materials is unethical. Rules of Ethics – Rule 10 Dr. Y sees Patient X for routine visit and notices development of a pigmented choroidal lesion. Dr. Y does not order photography to document the size and shape of the lesion because he has already ordered X-number of that test this month and ordering another test will cause his numbers to go “over the top” and will result in less reimbursement under his contract. Rules of Ethics – Rule 10 Dr. Y documents the findings, but down-plays the finding in the patient’s chart and notes, “Next visit, check status of pigmented lesion.” Questions? Patient #9 • Patient complains of “lesions” left upper lid x 2 weeks. Increasing in size, itching, no discharge. • Exam reveals two lesions – 0.2 cm in size • Probably benign – sending to pathology to confirm • ABN obtained from patient Patient #9 – Correct coding 11440 Excision, other benign lesion, except skin tag, eyelids, 0.5 cm or less 1. CPT code 11440-E1 and 11440-59-E1 2. CPT code 11440 3. CPT code 11440-E1 and 11440-51-E1 Patient #9 – Correct coding In addition to the appropriate level of exam appended by modifier 25 2. CPT code 11440. Code is payable per session, not per eye, not per lesion. Patient #10 Patient c/o “baggy upper lid skin” getting worse over several past years Exam performed, photographs and VF ordered and reveal need for combined functional ptosis and blepharoplasty procedures • The medical necessity for each procedure was individually documented Patient #10 • Interpretation and report reads, “The visual field defect is related to both ptosis and dermatochalasis” • Question: What is the weak-link in this documentation? Patient #10 • In addition to the appropriate level of exam, coding should be 92285 External ocular photography Inherently bilateral 92082 VF Inherently bilateral No modifier CCI bundle with 15823 $ (same date) No modifier N/A $ Patient #10 • Surgical coding 67904 Repair of blepharoptosis (tarso) levator resection or advancement -50; or E1 and E3; or RT and LT; and GA 15823 Blepharoplasty Add -51 to excessive skin above if required Not bundled with 15823 $662 2nd at 50% Not bundled with 67904 $306 50% reduction Patient #11 • What if one eye is functional and one is cosmetic? • Claim submission is not required for the cosmetic eye. • If patient insists, code 15822-Eye-GY Blepharoplasty, upper eyelid • V50.1 Other plastic surgery for unacceptable cosmetic appearance Patient #12 • Pt c/o dry eye x several months. +2 burning, frequent blinking. Previously tried artificial tears & ointment. Uses a humidifier – still no help. • Schirmer test and exam reveal keratitis OU • Physician will insert punctal plugs in two lower puncta Patient #12 • In addition to the appropriate level of exam, coding should be 68761 Closure of lacrimal punctum; by plug, each -50; or RT No CCI $137 and LT; or edits 50% E2 and E4 reduction for second procedure Patient #12 • In 2002 Medicare bundled the supply of the plug with the insertion • Non-Medicare payers may pay separately for the supply of the plug HCPCS code A4262 for collagen HCPCS code A4263 for silicone; or CPT code 99070 for supply. May require invoice Patient #12 • There is no CPT code for Schirmer test. • It is not a countable element of an exam • You can’t bill the patient with the unlisted procedure code Patient #13 • Following an exam on a glaucoma suspect patient, the physician orders a VF and optic nerve scan on both eyes Patient #13 • In addition to the appropriate level of exam, coding should be 1. Bill for the VF and OCT. 2. Bill for the optic nerve scan only the two codes are bundled in CCI. Optic nerve scan is payable per eye and VF are inherently bilateral. 3. Have the patient return for any testing as the services are bundled with the exam. Patient #13 • In addition to the appropriate level of exam, coding should be 1. Bill for the VF and OCT. CPT code 92083 $77 CPT code 92135-RT $45 CPT code 92135-LT $45 (no reduction) Patient #13 • Many 92135 LCDs state: - Once per year is appropriate to follow preglaucoma patients or those with “mild damage” - Patients with “moderate damage” may be followed with optic nerve or visual fields. One or two tests a year may be appropriate. Patient #14 • Patient is within the global period of an LPI. An anterior segment B-scans confirms the diagnosis of plateau iris syndrome. • An iridoplasty is scheduled Patient #14 76513 Anterior segment $98 RT B-scan 66762 Iridoplasty by $414 Modifier photocoagulation 78-RT (one or more sessions) No CCI edit No CCI edit Patient #15 • Surgical patient requires an injection of 5FU in the left eye postoperatively • The injection, with the appropriate modifier, is payable as is the drug • No office visit is charged Patient #15 • The correct modifier appended to the injection code is: 1. -58 2. -78 3. -79 Patient #15 68200 Subconjunctival injection J9190 Fluorouracil $39 -58 -LT $ N/A No CCI edit No CCI edit Patient #16 • Patient requires a scleral patch graft in conjunction with placing a drainage implant – left eye Patient #16 992XX Appropriate or level of exam 9201X 66180 Aqueous shunt to extraocular reservoir 90-day global $TBD -57 No CCI edit $1,007 -LT No CCI edit 67255 $ 374 -51 –LT (50%) No CCI edit Scleral reinforcement 90-day global Patient #17 • Patient within a global surgical period requires removal of sutures. Laser suture lysis is performed. Patient #17 • Suture removal by laser or other means is never payable in the postoperative period • Outside the global period, or if you are not the surgeon, it is part of the exam code billed Patient #17 • It is inappropriate to bill for: - CPT code 65222 Corneal FB; or - CPT code 66250 Revision, repair of operative wound Patient #18 • C/O “bump” both eyes, nasally on the white of the eye. Eyes are red and irritated. Chief complaint bump Location Both eyes Quality Duration Irritated Associated signs Red Patient #18 • Diagnosis pinguecula - CPT code 68110 Excision of lesion, conjunctiva; up to 1cm ($221); or - CPT code 68115 over 1 cm ($312) Patient #19 • Diagnosis pterygium - CPT code 65420 Excision or transposition of pterygium; without graft ($493) or - CPT code 65426 ($606) with graft Patient #19 • Use 65426 regardless of the source of the graft • CCI bundle with amniotic tissue transfer Patient #20 • Patient with progressive pterygium that needs excision. • Surgeon decides to perform at the same surgical encounter as cataract surgery in the same eye. Patient #20 66984 65426 Cataract extraction with IOL $664 Pterygium excision with graft $606 Eye Not modifier bundled with 65426 -51 –eye Bundled modifier with 66984 Patient #21 • Patient with progressive pterygium (left eye) that needs excision. • Surgeon decides to perform at the same surgical encounter as cataract surgery (right eye) Patient #21 66984 65426 Cataract -RT extraction with IOL (90-day) $664 Pterygium excision with graft (90-day) $303 (50% reduction) -59 -LT Not bundled with 65426 Bundled with 66984 Patient #22 • Patient requires cataract extraction plus IOL and corneal transplant Patient #22 CPT code 65730 RT or LT $1,560 CPT code 66984 51 and RT or LT $ 332 $1,892 Or CPT code 66984 RT or LT $ 665 CPT code 65730 51 and RT or LT $ 780 $1,445 Patient #23 Patient requires corneal transplant and IOL exchange Patient #23 CPT code 65755 RT or LT $1,066 CPT code 66986 51 and RT or LT $ 404 $1,470 Or CPT code 66986 RT or LT $808 CPT code 65755 51 and RT or LT $533 $1,341 Patient #24 Keratoplasty is the general term for several variants of corneal transplant. CPT code 65710 covers lamellar keratoplasty in which only the outermost layers of cornea are transplanted. CPT codes 65730, 65750, and 65755 refer respectively to full-thickness (penetrating) corneal transplant in an aphakic patient, an aphakic patient (with no native lens), and a pseudophakic patient (with an artificial lens). The physician work allowance (WRVU) for each of the three penetrating keratoplasty codes is similar. Patient #24 A relatively newer procedure is term “Descemet’s stripping endothelial keratoplasty (DSEK)” or “deep lamellar endothelial keratoplasty.” This procedure involves a small incision to allow intraocular placement of endothelium harvested from a donor cornea after the stripping off of diseased corneal endothelium. Patient #24 Microkeratome-based (automated) preparation of the donor endothelium may be used. This technique offers certain clinical advantages while achieving the goal of penetrating keratoplasty in patients with disease largely related to endothelial dysfunction. Patient #24 Until such time that a more specific code is released, many payers are allowing the new Descemet’s stripping procedure coded as 65730, 65750, 65755, or 66999 (based on the patient’s lens status). – Offices MUST confirm with the specific payer that this coding is correct. Patient #24 Coding with unlisted procedure code 66999 is not incorrect but will trigger delays for additional documentation requests, processing, review, and cross-walking of reimbursement, and resultant potential access to care concerns. Trailblazer states require 66999 for coverage. Questions? Explanation of Benefits • When processing EOMBs consider: - How well trained is the staff person? - See addendum - Explanation of Medical Benefits, Unlock Its Secrets Patient #25 • Patient has bilateral lateral rectus resections (both eyes previously underwent strabismus surgery). • Surgeon also explores the inferior obliques. Patient #25 67311 Strabismus surgery, recession or resection procedure; one horizontal muscle +67331 Strabismus surgery on patient with previous eye surgery +67340 Strabismus surgery involving exploration/and or repair -50 or RT and LT $516 -50 or RT and LT $260 Medicare only allows payment for one eye -50 or RT and LT Medicare only allows payment for one eye $306 Patient #26 • In addition to the primary strabismus surgery, the physician performed an adjustable suture. • But instead of adjusting the suture in the ASC recovery room following surgery, the adjustment was performed in the office the next day. Patient #26 Can CPT code +67335 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) be billed when performed the next day in the office? ($134) Patient #27 • Physician orders fundus photography (92250) and OCT (92135) performed on the same day. • The codes are bundled in CCI. • Is it ever appropriate to unbundle? Patient #28 • Physician orders optic nerve scan for a glaucoma and a retinal diagnosis? • Is it ever appropriate to bill 92135 per eye for each diagnosis? Patient #29 • Physician performed an exam, OCT and an injection of Macugen, Avastin, or Lucentis on a patient in a skilled nursing home. • Are there billing issues? Patient #29 CPT code Description 9921X-25 or Appropriate Exam level of exam 9201X-25 92135 OCT 92135-26-RT 92135-TC-RT 92135-26-LT 92135-TC-LT Injection Injection 67028-eye Unilateral payment 67028 HCPCS code Part B billing SNF billing Drug Patient #29 • Skilled nursing facility bill affects coverage for: - the technical (TC) component of special testing services - post-cataract glasses - injected drugs - NTIOLs Patient #30 – Retinal cases • Tip: Look at the diagnosis, the reason for surgery. The base vitrectomy code will either be a “repair of retinal detachment (RD) code” or a “vitrectomy” code. Patient #30 – Retinal cases Vitrectomy with Epiretinal Membrane Stripping • Until December 31, 2007 CPT code 67038-eye modifier • After January 1, 2008 CPT code 67041-eye modifier Patient #31 – Retinal cases Scleral Buckle, Vitrectomy and Epiretinal Membrane Stripping • Until December 31, 2007 CPT code 67038-eye modifier CPT code 67108-51-eye modifier • After January 1, 2008 CPT code 67113-eye modifier Patient #32 – Retinal cases Macular Hole Until December 31, 2007 CPT code 67038-eye modifier After January 1, 2008 CPT code 67042-eye modifier Patient #33 – Retinal cases Macular Hole with Retinal Tear • The surgeon finds a retinal tear during surgery to repair a macular hole. The tear is treated by endolaser. Until December 31, 2007 CPT code 67038-eye modifier CPT code 67039-eye modifier After January 1, 2008 CPT code 67042-eye modifier Patient #34 – Retinal cases Complex Diabetic Traction Retinal Detachments Until December 31, 2007 CPT code 67108-eye modifier CPT code 67038-51-eye modifier After January 1, 2008 CPT code 67113-eye modifier Patient #35 – Retinal cases Vitrectomy and Panretinal Photocoagulation for Diabetes For a straight forward vitreous hemorrhage treated with a vitrectomy and endophotocoagulation CPT code 67040-eye modifier Patient #35 – Retinal cases Vitrectomy and Panretinal Photocoagulation for Diabetes When extensive membrane stripping is done for the proliferative disease and endolaser panretinal photocoagulation Until December 31, 2007 CPT code 67038-eye modifier CPT code 67040-51-eye modifier After January 1, 2008 67040-eye modifier Lens complications The following procedures are bundled with 67036 Vitrectomy, mechanical, pars plana approach; in the CCI. 66820 66830 66840 66920 66930 66940 Discission of secondary membranous cataract Removal of secondary membranous cataract Removal of lens material; aspiration technique intracapsular intracapsular, for dislocated lens extracapsular Lens complications The next set of three codes were bundled with 67036 Vitrectomy, mechanical, pars plana approach. Unbundled January 2005. Modifier 59 no longer needed. 66982 66983 66984 Complex cataract Intracapsular cataract with IOL Cataract extraction with IOL Lens complications The next set of two codes were unbundled with 67036 Vitrectomy, mechanical, pars plana approach. Unbundled April 2003. Modifier 59 no longer needed. 66985 66986 Secondary IOL IOL exchange Lens complications •If vitrectomy is performed only to accomplish the cataract surgery then it is integral to the cataract surgery and not separately payable. Consultations – clarification language •Clarification A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition. Tips from the most effective offices Tips from the most effective offices Medicare fee schedule obtained/implemented by January 1st of each year Non-Medicare fee schedules obtained/implemented after July 1st of each year Tips from the most effective offices Quarterly run a procedure productivity report for each physician in the practice Identify these high-volume utilization codes Tips from the most effective offices Conduct an internal chart audit of two or three of the charts from that particular code for that period of time This is the way all payers conduct their audits Tips from the most effective offices Develop a protocol for processing requests for records from any source - Type any notes that aren’t legible Tips from the most effective offices Sign-up for payer list serves. Develop a protocol for disseminating pertinent information Tips from the most effective offices Review current LCDs. These are the rules and regulations by which you will be held accountable in an audit Tips from the most effective offices Review CCI impact on your coding each quarter - Coding Bulletin - Coding Coach - http://www.aao.org/aaoesite/coding/ Tips from the most effective offices Develop a protocol for working denials – within 72 hours of EOMB receipt Develop a protocol for processing refunds – insurance and patient Tips from the most effective offices Collect all copays, balances owed, refraction charges, etc, at the time of service Tips from the most effective offices Stay current with coding issues - Washington Report - EyeNet’s Savvy Coder - AAOE’s Coding Bulletin - AAOE’s etalk, eexpert, eretina Tips from the most effective offices Have documentation/coding as a topic at each staff meeting Physician Quality Reporting Initiative 2008 Update PQRI 2008 • Two components: - updates for 2008 - implementation guide for those who have not participated previously PQRI 2008 • There will not be a question and answer period for the call. • Questions may be submitted to [email protected] - Questions received will be added to the Q&A section of www.aao.org/pqri PQRI 2008 • CMS will again provide up to a 1.5 percent bonus for physicians who voluntarily report on quality measures during 2008, drawing on the $1.35 billion Physician Assistance and Quality Initiative Fund. PQRI reporting begins January 1, 2008 through December 31, 2008. PQRI 2008 • Ophthalmologists are welcome to use any measures that apply to their patient base • Complete details of all 134 measures can be found at http://www.cms.hhs.gov/PQRI/Downloads/2008P QRIMeasureSpecs.pdf PQRI 2008 – Deleted measures • Measure 13 Age-Related Macular Degeneration: Age-Related Eye Disease Study (AREDS) Prescribed/Recommended; • Measure 15 Cataracts: Assessment of Visual Function Status; • Measure 16 Cataracts: Documentation of PreSurgical Axial Length, Corneal Power Measurement and Method IOL Power Calculation; and • Measure 17 Cataracts: Pre-Surgical Dilated Fundus Evaluation PQRI 2008 – Current measures • Measure 12, Primary Open Angle Glaucoma: Optic Nerve Evaluation - addition of modifier 3P. Documentation of system reason(s) for not performing an optic nerve head evaluation PQRI 2008 – Current measures • Measure 14, Age-Related Macular Degeneration: Dilated Macular Examination - addition of modifier 3P. Documentation of system reason(s) for not performing a dilated macular examination PQRI 2008 – Current measures • Measure 18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy - addition of modifier 3P. Documentation of system reason(s) for not performing a dilated macular or fundus examination PQRI 2008 – Current measures • Measure 19, Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care This measure is now reported using CPT Category II code and HCPCS G codes. PQRI 2008 – Measure 19 • CPT Category II code 5010F findings of dilated macular or fundus exam communicated to the physician managing the diabetes care, and • HCPCS G code G8397 Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy PQRI 2008 – Measure 19 • What if the measure was not performed on a qualifying patient? PQRI 2008 – Measure 19 • 5010F - 2P patient reason for not communicating with PCP; or - addition of modifier 3P system reason for not communicating with PCP; or - 8P findings not communicated, reason not otherwise specified and PQRI 2008 – Measure 19 • G8398 dilated macular or fundus exam not performed - no modifier, just the HCPCS G code PQRI 2008 – Measure 117 • Dilated Eye Exam in Diabetic Patient • Definition: Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam PQRI 2008 – Measure 117 • Description - This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus. - This includes patients with diabetes who had one of the following: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the reporting period. PQRI 2008 – Measure 117 • Description - For dilated eye exams performed 12 months prior to the reporting period, an automated result must be available. PQRI 2008 – Measure 117 • CPT Category II Codes -2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; or - 2024F Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed; or - 2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed; or - 3072F Low risk for retinopathy (no evidence of retinopathy in the prior year) PQRI 2008 – Measure 117 • Code the Category II code in addition to the appropriate level of Evaluation and Management or Eye code exam: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99455, 99456 PQRI 2008 – Measure 117 • Modifier Application - 8P Dilated eye exam was not performed, reason not otherwise specified PQRI 2008 – Measure 124 • Health Information Technology (HIT) Adoption/Use of Health Information Technology (Electronic Health Records) PQRI 2008 – Measure 124 • Definition - To qualify, the provider must have adopted a qualified electronic medical record (EMR). For the purpose of the measure, a qualified EMR can either be a Certification Commission for Healthcare Information Technology (CCHIT) certified EMR or if not CCHIT certified, the system must be capable of all of the following: PQRI 2008 – Measure 124 • Generating a medication list • Generating a problem list • Entering laboratory tests as discrete searchable data elements • The measure is to be reported at each visit occurring during the report period. PQRI 2008 – Measure 124 • G Code (instead of Category II code) - G8447 Patient encounter was documented using a CCHIT certified EMR; or - G8448 Patient encounter was documented using a non-CCHIT certified EMR; or - G8449 Patient encounter was not documented using an EMR due to system reasons such as system being inoperable at the time of the visit. This implies that an EMR is in place and generally available PQRI 2008 – Measure 124 • CPT and HCPCS Codes 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97001, 97002, 97003, 97004, 97750, 97802, 97803, 97804, 98940, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, D7140, D7210, G0101, G0108, G0109, G0270, G0271 PQRI 2008 – Measure 124 • Diagnosis Codes - No diagnosis codes are associated with this measure • Modifiers - No modifiers are associated with this measure PQRI 2008 – Measure 125 • Health Information Technology (HIT) – Adoption/Use of e-Prescribing PQRI 2008 – Measure 125 • Definition • Qualifying providers have adopted an e-Prescribing system for all patients age 18 years and older and the extent of use in the ambulatory setting. To qualify this system must be capable of all of the following: • Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available • Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks - automated prompts that offer the provider information on the drug being prescribed, potentially inappropriate dose or route of administration of a drug, drug to drug interactions, allergy concerns, or warnings and cautions PQRI 2008 – Measure 125 • Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any) • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan PQRI 2008 – Measure 125 • HCPCS G Codes - G8443 All prescriptions created during the encounter were generated using a qualified e-Prescribing system; or - G8445 No prescriptions were generated during the encounter; or - G8446 Some or all prescriptions generated during the encounter were handwritten or phoned in due to one of the following: required by state law, patient request, or qualified e-Prescribing system being temporarily inoperable PQRI 2008 – Measure 125 • CPT and HCPCS Codes • 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G0101, G0108, G0109 PQRI 2008 – Measure 125 • Diagnosis Codes - No diagnosis codes are associated with this measure • Modifiers - No modifiers are associated with this measure PQRI 2008 – Implementation PQRI reporting is voluntary, not mandatory. • The reporting time frame is January 1 to December 31, 2008. PQRI 2008 – Implementation • The bonus is contingent on (a) achieving 80 percent success for patients that have a disease/diagnosis that a quality measure you selected is being reported (e.g., examining the optic nerve for a glaucoma patient) and (b) achieving that success rate for three quality measures (or fewer measures if less apply). PQRI 2008 – Implementation • The bonus will be paid out as a lump sum in mid2009. • The bonus will be applied to 100 percent of Part B billings for the period except for drugs, other biologics and durable medical equipment. There is a cap, which ensures that a physician who only reports a few cases doesn't get the same size bonus as a physician who reports quality measures frequently on his/her patients. Congress imposed a cap based on a complex formula. PQRI 2008 – Implementation • There is no need to sign-up to participate. Just begin to report the measures beginning January 1, 2008. • You cannot report on patients seen in nursing facilities or in Medicare Advantage programs. • Report on Medicare, Railroad Medicare, and Medicare as a secondary payer. PQRI 2008 – Implementation No dollar amount is listed in the Medicare Fee Schedule for the Category II or G codes, but the charge box should not be left blank. If your system or the payer system won’t accept a zero charge, post 0.01. PQRI 2008 – Implementation Not everyone in the practice has to select the same measures. Nor does everyone in the practice need to participate. Since the individual reporting is based on the NPI, only those patients treated by that physician will count towards the 80 percent and the bonus calculation. However the more participating physicians in the practice, the greater the total bonus. PQRI 2008 – Implementation • Begin by selecting the measure(s) applicable to you. • Make sure your computer software will accept the Category II and G codes as well as the P modifiers. • Consider running a diagnosis code productivity report from the list of denominators (diagnosis codes) for the measure(s) you’ve selected. This will alert you as to which additional diagnosis codes are available that you might not be using already. PQRI 2008 – Implementation • PQRI Modifiers - There will be situations when a modifier is appropriate in addition to the Category II or G code to explain why a measure could not be completed. - 1P Documentation of medical reason(s) for not performing a measure. - 2P Patient declined for economic, social, or religious reasons. - 3P Performance measure exclusion modifier due to system reasons. Insurance coverage/payer related limitations or resources to perform the services not available. - 8P Reasons not otherwise specified. •PQRI for 2009? PQRI 2009 • 5 new and 1 revised eye measures have been approved by the AMA PCPI and AQA • Not included by CMS in the final rule – Academy working to seek implementation Questions? Door Prizes
