Transcript Coding Basics- Don*t Fall Asleep - Heart of America Contact Lens

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

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





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,

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




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
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!!