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Key Elements to
Effective Medical
Eye Care Coding
and Billing
1
When a Patient Enters Your Practice
What does the patient want?
What does the patient need?
What do you perform or provide for the patient?
What are the patient expectations?
What would you want if you were the patient?
2
Obtaining Third Party Information
Seek information
as soon as
possible in the
process
 Telephone-appointment scheduling
 In person-copies of vision and/or medical
plan cards and/or plan information pages
Don’t expect the
patient to know
their plan or
coverage
Be familiar with
your local area
companies and
their plan coverage
3
Obtaining Third Party Information cont.
Verify coverage
(obtain authorization
as soon as possible)
Depending on the
nature of the visit,
determine if medical
plan deductibles
have been met and
determine any copayments
Doctor and staff
must exhibit
confidence about the
practice’s role in
medical eye care
and medical plan
activities
4
Advance Beneficiary Notice (ABN)
 First issued October 1, 2002
 Used for services and materials
 Not required for items excluded by
statute, such as refraction, contact
lenses not covered and eyeglasses
not covered
 Submit claims with -GA modifier
 New ABN @ www.cms.hhs.gov/bni
5
Health Care Procedural Coding System (HCPCS)
Level I HCPCS
Level II HCPCS
Level III HCPCS
 CPT-4 Procedure codes
 Alpha-numeric codes to allow
billing of supplies, such as V2200
bifocal lenses
 Local codes
6
ICD Diagnosis Codes
International Classification of Diseases
(ICD)
7
Diagnosis Codes
 Developed and controlled by the World
Health Organization (WHO)
 The key to payment of billed procedure
codes
 Linked codes to procedure codes
 Valuable to payers to track conditions
and statistics
 Change to alpha-numeric ICD-10 in 2013
8
Diagnosis Codes
 HHS has established that ICD-10 codes
be used by health care providers to
report diagnosis with procedures
beginning October 1, 2013
 ICD-9 contains 17,000 codes where
ICD-10 will increase to 155,000 codes
 Introduction to HIPAA 5010 at
www.CMS.gov/MLNMattersArticles
 AOA Third Party Center will provide
educational materials-Be proactive!
9
Glaucoma
H40
Glaucoma
Excludes: absolute glaucoma (H44.5)
congenital glaucoma (Q15.0)
traumatic glaucoma due to birth injury (P15.3)
H40.0
Glaucoma suspect
Ocular hypertension
H40.1
Primary open-angle glaucoma
Glaucoma (primary)(residual stage):
· capsular with pseudoexfoliation of lens
· chronic simple
· low-tension
· pigmentary
H40.2
Primary angle-closure glaucoma
Angle-closure glaucoma (primary)(residual stage):
· acute
· chronic
· intermittent
H40.3
Glaucoma secondary to eye trauma
Use additional code, if desired, to identify cause.
H40.4
Glaucoma secondary to eye inflammation
Use additional code, if desired, to identify cause.
H40.5
Glaucoma secondary to other eye disorders
Use additional code, if desired, to identify cause.
H40.6
Glaucoma secondary to drugs
Use additional external cause code (Chapter XX), if desired, to identify drug.
H40.8
Other glaucoma
H40.9
Glaucoma, unspecified
10
ICD-9 Codes
International
Classification of
Disease, Ninth
Edition
Diagnosis Codes
 Typically, a 5 Digit Code
with a Decimal Point
 123.45
Can be a 4 Digit
code, however be
suspicious
 123.4
11
ICD Diagnosis Codes
 List primary diagnosis code first and all other ICD codes after
 Use most detailed and specific code(s) possible for each submission
 List all pertinent diagnosis for each patient for claims

Some medical plans reject refractive diagnosis

Most vision plans today DO NOT reject medical diagnosis

Many vision plans require the submission of all applicable ICD diagnosis codes for all patients (refractive and
medical)
 Avoid xxx.9 codes whenever possible
 Codes may need to be line item specific for procedures linked to different
diagnosis
12
ICD Diagnosis Codes cont.
 379.2-Disorders of
vitreous body
Verify coverage
(obtain authorization
as soon as possible)
 Vitreous
Degeneration
 379.21-Vitreous
degeneration
 379.9-Unspecified
disorder of the eye
and adnexa
13
V-Diagnosis Codes

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(s)
14
V-Diagnosis Codes cont.

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
15
Diabetes
Diabetes
Mellitus-ICD
250.xx
 250.0_-Diabetes
w/o complication
or manifestation
 250.5_-Diabetes
with ophthalmic
manifestations
 5th digit
 0-Type 2 or unspecifiednot stated as
uncontrolled
 1-Type 1-not stated as
uncontrolled
 2-Type 2 or unspecifieduncontrolled
 3-Type 1-uncontrolled
16
Diabetic Retinopathy
If diabetic
retinopathy is
present, appropriate
coding is to list
250.5x plus
Type of diabetic
retinopathy present
 362.03-Not otherwise specified (NOS)
 362.04-Mild Non-proliferative
 362.05-Moderate Non-proliferative
 362.06-Severe Non-proliferative
 362.07-Diabetic Macular Edema
17
Selecting The Appropriate Procedure Code
Identify
appropriate
Category of
Service
Evaluation/Management
EM
 Determine extent of History
 Determine extent of
Examination
 Determine extent of Medical
Decision Making
Ophthalmological (must
meet requirements and
definitions listed)
“S” Code
Consultation
 Determine extent of History
 Determine extent of
Examination
 Determine extent of Medical
Decision Making
18
Utilization Patterns Medicare-Ophthalmology-2008
CPT
New
Patients
Usage
CPT
Est
Patients
Usage
99205
Level 5
2%
99215
Level 5
1%
99204
Level 4
18%
99214
92014
Level 4
Comp
49%*
99203
92004
Level 3
Comp
73%*
99213
Level 3
Int
44%*
99202
92012
Level 2
Int
8%*
99212
Level 2
5%
99201
Level 1
0%
99211
Level 1
0%
* Combined utilization of E/M and Eye Codes
19
Utilization Patterns Medicare-Optometry-2008
CPT
New
Patients
Usage
CPT
Est
Patients
Usage
99205
Level 5
1%
99215
Level 5
1%
99204
Level 4
14%
99214
92014
Level 4
Comp
50%*
99203
92004
Level 3
Comp
75%*
99213
Level 3
Int
42%*
99202
92012
Level 2
Int
9%*
99212
Level 2
6%
99201
Level 1
0%
99211
Level 1
0%
20
Utilization Patterns - Optometry
 New Patient Codes
 Combined 92004/99203-75%
92004-65%
 99203-10%

 Established Patient Codes
 Combined 92014/99214-50%
92014-41%
 99214-9%

21
Develop Your Practice Metrics
Ocular
Surface
Disease/
Dry Eye
 Reported prevalence
in the population =
25-30%
 What is your
percentage of OSD
work-ups and
treatment?
 Office service follow-up
(99212-99214)
 Dilation and irrigation
(68801)
 Punctal occlusion
(68761)
22
Develop Your Practice Metrics cont.
Glaucoma
 Reported prevalence in
the population = 1-3%
with some population
segments as high as
11.5%
 Office service follow-up
(99212-99214)
 What is your percentage
of glaucoma work-ups
and treatment?
 Fundus photography (92250)
 Visual field analysis (92083)
 Gonioscopy (92020)
 Serial tonometry (92100)
 Scanning laser (92135)
 Pachymetry (76514)
Decreases
23
“The
Great
Decreases
Debate”
Vision Plan or Medical
Plan Billing
24
Case Example
Patient presents vision plan card
(has PPO Managed Health Care
Plan) and is seeking new Rx
History and clinical findings
reveal:
 Ocular Surface Disease that
appears inflammatory based
 A quality refraction is
completed and Rx determined
What options for billing exist?
25
Case Example cont.
Option 1
 Bill comprehensive examination to Vision Plan
 Self-refer/reschedule for OSD work-up
 Bill comprehensive examination to PPO
Option 2
 Refraction (92015) to Vision Plan
 Self-refer/re-schedule for follow-up to OSD
treatment plan
26
Billing Considerations
Is your office a participating provider on the PPO medical plan
Increases
What is the time of the year
What were the patient’s expectations entering the office
Does the Vision Plan have a primary eye care program to allow
extended medical eye services to be billed
Is the billing option presented consistent with other payer types in
Decreases
the practice
27
?
Who
is the Ultimate
Increases
Decision Maker of What
Plan Will Be Billed
Decreases
The Holder of
the Coverage!
28
Billing Considerations
Confidence
Increases
Communication
to
patient/family
Decreases
Managing the
schedule
 Explain findings as your clinical tests
progress
 Stop and recommend course of care as well
as coding/billing
 Establish expectations for care and schedule
 Re-schedule as indicated by condition(s)
29
Unfortunate Example
Monday, May 05, 2008 – xx Dept of Insurance
xxxx-area Optometrist Guilty of Insurance Fraud Totaling Nearly $11,500.
Increases
Dr. xxx xxxx faces six to 12 months in prison.
xxxx – xxx xxxx, a xxxx-area optometrist investigated by the xx Department of Insurance for insurance fraud, pled no
contest today to a Bill of Information charging Him with one count of insurance fraud, a felony of the fifth degree thereby
waiving his right to be indicted. xxxx was found guilty of illegally billing insurance entities Anthem, United Health Care
and Tricare and fraudulently receiving nearly $11,500 for personal gain.
Department Fraud and Enforcement attorney xxx xxxx served as special prosecutor in the case before the xxxx County
Court of Common Pleas. xxxx sentencing hearing is scheduled for June 17 at 10 a.m. He faces a potential prison
sentence from six to 12 months.
Decreases
xxxx used several fraudulent schemes, including charging patients $21 for a visual fields test procedure. He would, in
some cases, advise the patients that their insurance would not cover this test but that it was important that they have it.
The patients would pay him their co-payments as well as the $21. He would only show the co-payments on the
insurance submissions then bill the insurers and pocket the money. He would also bill for a bogus mucous membrane
test that required a special allergen – which the office did not have – to be inserted into the eye membrane.
xxxx who suspect insurance fraud should call the Departments fraud hotline at 1-800-xxx-xxxx..
30
Increases
Decreases
Medical
Eye Care
31
Medical Necessity is:
Medicare:

Services that are proper and needed for the diagnosis or
treatment of the patient’s medical condition(s), are provided for
the diagnosis and direct care and treatment of the patient’s
medical condition(s), meet the standards of good medical
practice in the local area and aren’t mainly for the convenience
of the patient or physician.
Increases
Other coverage definitions:
Decreases
 Treatment based on evidence-based medical standards, or the
treatment is considered by most physicians in your community to
be clinically appropriate
32
What is of Primary
Importance for Billing a
Medical Visit
A Chief Complaint
33
Chief Complaint
“The coverage of services rendered by a physician is dependent on the
purpose of the examination rather than on the ultimate diagnosis of the
patient’s condition. When a beneficiary goes to a physician with a complaint
or symptoms of an eye disease or injury, the physician’s services (except for
eye refractions) are covered regardless of the fact that only eyeglasses were
prescribed. However, when a beneficiary goes to his/her physician for an eye
exam with no specific complaint, the expenses for the examination are not
covered even though as a result of the examination the doctor discovered a
pathological condition.”
Increases
Decreases
Bottom Line: To qualify for reimbursement, you must establish a link
between the chief complaint and the submitted diagnosis
34
Selecting and Using
Evaluation/Management
(E/M) Codes
35
Elements of E/M
Coding
History*
Coordination of Care
Examination*
Nature of Presenting
Problem
Medical Decision
Decreases
Making*
Time
Counseling
* Key Elements
36
Time
 “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
Decreases
the medical record.”
37
Typical Times in CPT-4
Increases
 99205-60 minutes
 99215-40 minutes
 99204-45 minutes
 99214-25 minutes
 99203-30 minutes
 99213-15 minutes
 99202-20 minutes
 99212-10 minutes
Decreases
 99201-10 minutes
 99211-5 minutes
(Non physician)
38
Documentation Guidelines
 Adds detail to E/M original definitions
Increases
 Need to obtain a copy of 1995 or 1997 Guidelines
and be aware of what standards you will be held
to
 A copy of the 1995 and 1997 guidelines are
Decreases
available at CMS website at:
http://www.cms.hhs.gov/MLNProducts/downloads/
referenceII.pdf
39
Medical Decision Making
 Minimal-One self-limited or minor problem
 Low-Two or more self-limited or minor problems; One
stable chronic illness; One acute uncomplicated illness
or injury-Treatment w/ OTC medication
 Moderate-One or more chronic illness…; Two or more
stable chronic illnesses; Undiagnosed new problem
(uncertain prognosis); Acute illness with systemic
symptoms; Acute complicated injury- Treatment w/
prescription medication
 High-One or more chronic illnesses w/ progression;
Acute or chronic illnesses or injuries that pose a threat
to life or bodily function; abrupt change to neurological
status-Treatment w/ therapy that requires toxicity
monitoring
40
Source: 1997 Documentation Guidelines
Consultations
Decreases
41
Consultation Requirements
Consultation-…Service
Increases
provided
by a physician
whose opinion or advice
regarding evaluation
and/or management of
a specific problem is
Decreases
requested by another
physician or other
appropriate source.
Needed elements:
 Request
 Render Opinion
 Report of findings to requesting
physician or other source
42
E/M Consultation Codes
The Federal Register, Vol. 74, No. 226 posted
November 25, 2009, contains CMS’ final decision to
eliminate both outpatient consultations (99241 – 99245)
and inpatient consultations (99251 – 99255) for
payment purposes. CMS cites lack of understanding and
confusion over their use as the rationale to eliminate
them. Physicians should use either evaluation and
management (992xx) or ophthalmology (920xx) codes
in place of outpatient consultations.
43
Increases
Decreases
Special
Ophthalmological
Services
44
Other Specialized Services
92020-Gonioscopy (B)
Increases
92025-Corneal
Topography (B)
92081-Visual Field (B)
92082-Visual Field (B)
Decreases
92083-Visual Field (B)
92100-Serial Tonometry (B)
Must use multiple readings (3 minimum) in
the same 24-hour period
45
Other Specialized Services cont.
92135-Scanning computerized
imaging with interpretation and
report (U)
 Bundled by many payers with
92250 or 92083 if billed at
same session (use an ABN!)
 Not truly indicated in
advanced disease
92225-Ophthalmoscopy
extended, with retinal drawing,
interpretation and report, initial
(U)
Decreases
92226-Ophthalmoscopy,
subsequent (U)
46
Other Specialized Services cont.
92250-Fundus photography w/
interpretation
Increasesand report (B)
92283-Color vision
examination, extended (B)
92285-External ocular
photography w/ interpretation
and report for documentation of
medical progress (B)
47
OCT-Anterior Segment
Category III
Code
 0187T-Scanning computerized
ophthalmic diagnostic imaging, anterior
segment with interpretation and report,
unilateral
 Coverage and payment for Category III
codes remains at carrier discretion
Decreases
48
Billing Specialized Services
Baseline or routine
testing is
Increases
inappropriate
List in clinical
records the order
for the test
Decreases
 Must base test order on medical
necessity
 Be aware of coding/testing
requirements from payer
 Bill with office service, if appropriate,
and use modifier where indicated
 Use interpretation and report where
needed
49
Interpretation and Report
 Indications for performing the test
 Test results with notation of reliability
 Use of test results in treatment and
management of the condition
 Initiate treatment or plan to repeat testing
or other care
 Where possible, initial and date the test
Decreases
form
50
Modifiers
51
Selecting the Appropriate Modifier
 -24 Unrelated E/M Service, Same Physician, During Post-op period
 -25 Separate Service, Same Physician, Same Day
 -26 Professional Component
Increases
 -50 Bilateral Procedure
 -51 Multiple Procedures
 -52 Reduced Service, Informational, Not Reduced Fee
 -54 Surgical Care Only
 -55 Post-Operative Care Only
 -58 Staged Procedure
Decreases
 -59 Distinct Procedural Service
 -79 Unrelated Procedure, Same Physician, During Post-Op
 -TC-Technical Component
 -RT/LT Right, Left
 -E1 – E4 Puncta/Lid Identifiers
52
Modifier-25
Significant,
separately
IncreasesE/M
identifiable
service
“The patient’s medical record
documentation is expected to clearly
evidence that the evaluation and
management service performed and
billed was “above and beyond” the
usual pre-operative and post-operative
care associated with the procedure
performed on that day”
Decreases
53
Modifier-25 cont.
The need to perform an independent evaluation and
management service may be prompted by a complaint,
symptom, condition problem or circumstance which
may
or may not be related to the procedure (or other
Increases
service) provided.
As such, different diagnosis from those related to the
procedure are not required for reporting of a significant,
separately identifiable E/M service performed on the
same day.
Decreases
However, the record should document an important,
notable, distinct correlation with signs and symptoms to
make a diagnostic classification or demonstrate a
distinct problem.
54
Healthcare
Effectiveness
Data and
Decreases
Information Set
(HEDIS)
55
HEDIS
 Used by over 90% of the health care plans
 73 provider services that managed care plans must provide
for their covered lives
 Many administrative services on required list
 Two eye services included:

Yearly dilated eye examination for all diabetic patients
Decreases
 Glaucoma screening for high-risk patients
 Currently dilated eye examination is the lowest percentage
score of all services in HEDIS
56
What is Disease Management?
Disease Management
is a system of
coordinated
health
Increases
care interventions and
communications for
populations with
conditions in which
patient self-care efforts
are significant
 Supports the physician or practitioner/
patient relationship and plan of care,
 Emphasizes prevention of exacerbations
and complications utilizing evidence
based practice guidelines and patient
empowerment strategies, and
 Evaluates clinical, humanistic and
economic outcomes on an ongoing basis
with the goal of improving overall health
Decreases
57
Disease Management and Eye Care
 Integration of “all” health information via ICD-9 diagnosis codes
 Until recently, data has been limited to medical and pharmacy data
 Addition of dental data has yielded new standards for
gingivitis/pregnancy
 Eye care data is the next threshold and expected to yield valuable
correlations
Decreases
 Expect reporting incentives around DM area in the future
58
Diabetes Disease Management
Health plans and DM organizations are providing
Return
on Investment (ROI) guarantees, proving
Increases
that cost savings/avoidance has been validated
Diabetic cost avoidance in a recent study shows
direct and indirect diabetes cost avoidance of
Decreases
$14,012/year*
*Disease Management: Volume 11, Number 3, June 2008
59
Increases
Documenting
the Health Record
“Bullet Proof” Your Records
Decreases
60
Medical Record Guidelines
The medical record
should be complete
and legible
The documentation of
each patient encounter
should include:
 Reason for the encounter and relevant
history physical examination
 Findings and prior diagnostic test results
 Assessment, clinical impression or
diagnosis
 Plan for care
 Date and legible identity of the observer.
61
Medical Record Guidelines cont.

If not documented, the rationale for ordering
diagnostic and other ancillary services should be
easily inferred

Past and present diagnoses should be accessible to
the treating and/or consulting physician

Appropriate health risk factors should be identified

The patient's progress, response to and changes in
treatment, and revision of diagnosis should be
documented

The CPT and ICD-9-CM codes reported on the health
insurance claim form or billing statement should be
supported by the documentation in the medical
record
62
Source: 1997 Documentation Guidelines
Resources
Tools for success:
 CPT 2009
 ICD-9 2009
 HCPCS Level II 2009
All of these are
available in AOA
Codes for Optometry
63
Questions?
64
THANK YOU!
65