Transcript Ask the AOA Coding Experts: Vision versus Medical? Doug Morrow

Ask the AOA Coding Experts:
Top Ten Questions
Harvey Richman, O.D.
Rebecca Wartman, OD
Doug Morrow, OD
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, 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
AOA Third Party Center Coding Experts
Rebecca Wartman OD
Douglas Morrow OD
Harvey Richman OD
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 Supplied or Do
 Modifiers
What’s Different
CPT Procedure Codes
 Identifies physician services and procedures
 Copyright held by the American Medical Association
 Updated yearly through CPT Editorial Process
 Changes effective January 1 every year
Question 1A
Interpretation of Testing
I just bought an OCT.
The company installed and taught us how to
use it but they didn’t teach us how to
interpret it.
Can you teach us?
Question 1A
Interpretation of Testing
 NO! We cannot teach you how to interpret your OCT findings
 BUT We can give you coding guidelines for OCT use
 AND
 Resources to learn how to interpret findings:




Lectures
Websites
Manufacturer materials
Experience
Question 1
Dilation
 I was told by one of my friends that I should only
use intermediate level codes for routine eye
exams but I dilate all my patients.
Doesn’t that make them comprehensive exams?
Question 1
Dilation
Not necessarily!
 General Ophthalmic Services Codes
New Patient vs. Established
Comprehensive vs. Intermediate
 Elements of services
 Guidance on coding
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
Comprehensive Ophthalmological 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
Intermediate Ophthalmological 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 w/ 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 or treatment
services Consultations
• Laboratory procedures
• Radiological services
General Ophthalmologic Services
How Differ from E&M
Intermediate & Comprehensive
Ophthalmological Services:
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 Services
Intermediate
Some Medicare Carriers further define
what constitutes Intermediate and
Comprehensive Ophthalmic
Examinations
Source appears to be CPT Assistant
Article August 1998 and the CPT
introduction and definitions
This review helps in determining
intermediate vs comprehensive service
levels
COMPREHENSIVE
General Ophthalmologic Services
Ten Elements of Ophthalmologic Examination
• Confrontation fields
• Eyelids/adnexa
• Ocular motility
• Pupils/iris
• Cornea
• Anterior Chamber
• Lens
• Intraocular pressure
• Retina (vitreous, macula, periphery, and vessels)
• Optic disc
(Should be 12 elements including acuity and bulbar and palpebral
conjunctiva but not always listed)
General Ophthalmologic Services
Comprehensive examination
eight or more elements including:
Fundus examination with dilation**
Motor evaluation
**Note that CPT definitions do NOT
require dilation but some carriers dosome with further statement “with
dilation unless contraindicated”
General Ophthalmologic Services
Intermediate Examination
Seven or fewer elements
AND
Additional Ophthalmic Tests
Question 2
Refraction
 Since insurance is not covering, my patients
are getting mad about my refraction and
contact lens exam fees.
Is there a way that I can incorporate them
into my eye exam fee?
Question 2
Refraction
 Refraction and HIPAA
 Contact Lens Codes
 Inducement Violations
 S-Codes
 Presentation of fees to patient
General Ophthalmologic Services
Special Ophthalmological Services
92015 to 92140
Reported in addition to general ophthalmological services or E&M
services
Interpretation and report by the physician or QHP is integral part of
special ophthalmological services where indicated
Refraction-92015
 Determination of refractive state
 Statutorily not covered by Medicare
 RVU $20.42
 Consider Modifiers
General Ophthalmologic Services
Coding Guidelines
Refraction not covered by Medicare
May file for denial
GY modifier may be necessary
• indicates that the service
is statutorily excluded
from Medicare coverage
Advanced Beneficiary Notice (ABN)
S-Codes
 S0620 – routine ophthalmologic
examination including refraction, new
patient
 S0621 -- routine ophthalmologic
examination including refraction,
established patient
Routine Examination Codes?
S CODES PROBLEMS
No valuation
No further definitions
Insurers free to interpret at will
Fee Presentation
 Just because the patient has insurance doesn’t mean
that the procedure is covered
 Know the plans and how to present to patient
 Plan rules not always HIPAA Compliant
Question 3
Cataract Post op
 I keep getting denials from Medicare for
submission of a second eye cataract
post op.
What am I doing wrong?
Question 3
Cataract Post Op
Modifier Use
Surgical Correct Billing Guidelines
Post Op
 Surgeon
-54 modifier indicating surgical care only
 Post-op period = 90 days
 2017 and beyond?
 Surgery day = Day 0
 Transfer of care
 Transfer date
 Surgical Procedure
 Surgical Diagnosis
Post Op-Modifiers
-55 modifier
-79 modifier
RT modifier
LT modifier
Key Points Summary
 Thorough documentation is vital
 Communication with the surgeon is critical
 Surgeon must document the exchange of care
 Patient must understand exchange of care process
 Patients must have choice for post-operative care
 Communication with the patient is critical
 ALWAYS act in the best interest of the patient
Question 3A
Cataract Post Op
 How do you handle a patient that is covered by
a commercial carrier, is under 65 and has
cataract surgery and the insurance company
tells you they will not pay for co-management?
Do I bill E&M’s for the post op?
Do I fight with the carrier? Or both?
Question 3A
Cataract Post Op
Insurance company policies
Options?
 Bill Patient
 Bill Surgeon
 Write Off
Question 4
Fundus Photography
 My camera company told me that since
my camera does a better job of looking
for retinopathy then I do, that I can I use
that instead of dilating my diabetic
patients and bill 92250. It makes sense.
Question 4
Fundus Photography
 Fundus Photography
 Diabetic Eye Exam Requirements
 PQRS requirements
Diabetes and Retinal Examinations
American Diabetes Association and the National Institutes of Health’s positions
retinopathy is estimated to take at least 5 years to develop after the onset of
hyperglycemia
patients with type 1 diabetes should have an initial dilated and comprehensive
eye examination within 5 years after the onset of diabetes
Patients with type 2 diabetes should have an initial dilated and comprehensive
eye examination soon after diagnosis.
Subsequent examinations for type 1 and type 2 diabetic patients are generally
repeated annually
Diabetes and Retinal Examinations
American Diabetes
Association and the
National Institutes of
Health’s position
Photos are not a substitute
for a comprehensive eye
exam
92250 Purpose
CPT® 92250 considered medically necessary to monitor pathology
Reimbursed by Medicare and other third party payers per
guidelines for fundus photography
92250 Technology
 CPT® defines code 92250 as “Fundus photography with interpretation and
report” and makes no mention of the technology used to acquire the image.
There has been some confusion based on one CMS carrier, Palmetto GBA, which
has an LCD (local coverage determination) where it is stated in the Coverage
Indications, Limitations, and/or Medical Necessity section that “Fundus
photography uses a special camera to photograph structures behind the lens of
the eye including vitreous, retina, choroids, and optic nerve. This procedure
does not include laser scanning of the retina.” A few other CMS carriers add
variations of the following: “…..use of a retinal camera….and
photograph”. Those terms can be potentially confusing since technology to
create a photograph has changed significantly in the last several decades.
 It continues to be AOA’s position that when billing for any service or procedure,
your prudent step is to follow, to the best of your ability, the coding definitions
and coverage policies , whether they are by CPT®, a Medicare contractor or a
third party payer.
#5 Routine or Medical
 A patient came in complaining of flashes
of light and red eyes for the past two
weeks. After doing a total eye exam, I
found that he had a PVD, bilateral
cataracts and his corneas were beat
from sleeping with his daily disposable
contacts. How do I code for my time
when he only has Vision Plan X?
Medical vs Wellness
Patient with Medical Plan & well vision plan
 At exam completion, fees are reviewed
 Patient announces expectation for exam to be covered
by his well vision plan
 WHAT DO YOU DO?
 Clearly exam has medical presentation, history & exam
Medical vs Wellness
Patient with Medical Plan & well vision plan
 Many offices are faced with this dilemma
 More and more Medical Plans are adding wellness care
Options:
1. Perform well vision exam and reschedule for medical
2. Inquire upon patient arrive which plan intend to use
3. Bill Medical Carrier →exam & Bill well vision
→glasses
4. Bill Medical carrier & cross file to well vision plan for
copay, refraction and glasses, if allowed
Well Vision Examinations
Coding approaches across nation
 Internally use S code for all well vision
 Internal code only
 Converted to “plan accepted code” (92 series?)
 All routine patients –same exam=same fee concept
 Payment method disregarded in coding
 92 and 99 would be used only for medical
 Refraction separate
 Concern: “different” charge for same code when
actually filed to insurance
Current Advice
 Doctors need to make hard decisions on how will
handle BEFORE they occur
 Doctors need to thoroughly and completely TRAIN staff
on policies
 Doctors need to thoroughly and completely read Well
Vision Carrier policies
 Doctors need to carefully consider WHICH Well Vision
Plans they will accept
Guiding Principles to Consider
1. The chief complaint & examination findings should RULE
examination content AND coding
 My vision has gradually gotten worse, especially at near, no
known ocular disease
 Findings- presbyopic shift, no medical issues → Well vision
examination
 Findings – early ARMD → Medical examination
 Examination content and technique for each similar but
findings require more extensive examination, more
knowledge and more risk
 Medical examination leads to other testing, often
Guiding Principles to Consider
2.Plans accepted MAY have contract limitations on when
must use well vision plans and if coordination of benefits
may occur
• Some plans allow Coordination of benefits (COB)
• Some plans are changing their guidelines to force medical care
under the well vision plan service
• Some plans are rolling more medical testing under their well
vision plans
• Some plans are requiring the listing of medical diagnoses in
addition to the refractive diagnoses applicable
• PROVIDERS MUST READ AND UNDERSTAND THEIR CONTRACTS
SO ARE ABIDING BY THE RULES!
Guiding Principles to
Consider
3. Develop office policies and approaches to this common issue
THEN stick to them!!
• Avoid making rules for the rare exceptions
• Ensure excellent education of staff and patients
• Understand the consequences of your office policy decisions- you
cannot go wrong with well thought out polices
• Accept the fact that you may lose a few patients
• Review your policies yearly to ensure these policies still meet the
needs of your practice
Guiding Principles to
Consider
4. Do apply the CPT codes and coding rules correctly and across
the board
 Remember waiving copays without clear case by case hardship
documentation is considered fraud
 Remember that waiving charges for procedures without clear
case by case hardship documentation is considered fraud
 Remember to develop policies that prevent fraud and abuse
and uphold HIPAA rules
Question 5A
Meaningful Use
 I want to meet Meaningful Use, but it is
too hard for my staff to enter into the
computer.
Can I just check off the boxes because I
write it all down correctly on the record?
Question 5A
Meaningful Use
 Meaningful Use 2 guidance
 AOA resources
 Meaningful Use audits across the country
Question 6
Foreign Body
 If a patient comes in with a complaint of
something flying in his eye and I find a
foreign body, how do I bill it?
I heard someone once say you can’t bill
an office visit, is that true?
Question 6
Foreign Body
 Modifiers
 Surgical Correct Billing Guidelines
 New Patient vs Established Patient
 ICD-10-CM rules
Foreign Body Removal
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
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
65205 Conjunctival FB Removal, superficial
65210 Conjunctival FB Removal, embedded
65220 Corneal FB Removal w/o Slit Lamp
65222 Corneal FB Removal w/ Slit Lamp
Foreign Body Removal
 ICD-9 diagnosis codes
 930.1 Conjunctival Foreign Body
 930.0 Corneal Foreign Body
 ICD-10 diagnosis codes




T15.00 Foreign body in cornea, unspecified eye
T15.00XA Foreign body in cornea, unspecified eye, initial encounter
T15.00XD Foreign body in cornea, unspecified eye, subsequent encounter
T15.00XS Foreign body in cornea, unspecified eye, sequela
 Procedure billed stand alone
 Procedure billed with E&M code
Multiple Foreign Body Removal
Same code for one or multiple
foreign bodies
-51 modifier (multiple procedures)
-50 modifier (bilateral procedures)
Other Corneal Procedures
65430 Scraping of cornea,
diagnostic
65435 Removal of corneal
epithelium
Supporting ICD-10 Codes
 Scrape and Culture Cornea
 +H16.00 Unspecified corneal ulcer
 Debridement of Cornea
 H18.83 Recurrent erosion of cornea
 B00.52 Herpesviral keratitis
 H18.51 Endothelial corneal dystrophy
 Fuchs' dystrophy
Billing Surgical Codes
 Surgical codes are “stand alone” codes
 Not usually billed with E&M codes
 -25 modifier if E&M visit results in
decision for surgical procedure
Question 7
Multiple Procedures
 My glaucoma patient can only come in once
per year because their daughter visits only in
the summer. I need to do ophthalmoscopy,
fundus photos, gonioscopy, pachymetry,
fields and OCT on that day or else she will
never get it done. I was told that we can do
that.
What should I do?
Question 7
Multiple Procedures
 Multiple Procedure Payment Reduction
 Modifiers
 Medical Necessity
 Local Coverage Determination (LCD) for
Services That Are and Are Not Reasonable and
Necessary
 Patient education
Multiple Procedure Payment
Reduction Modifications
 20% reduction to practice expense
component for 2+ service(s) furnished
by a physician or group practice in an
office setting on same day
Multiple Procedure Payment
Reduction Modifications
 April 1, 2013, American Taxpayer Relief Act of
2012 applied up to 50% multiple procedure
payment reduction modifications (MPPR)
 20% reduction to technical component for 2+
diagnostic ophthalmology services furnished
to same patient-same physician-same day
 50% reduction for 2+ surgical procedures
furnished to same patient-same physiciansame day
Multiple Procedures on Same Day
76510-76513
76514
92025
92060
92081-92083
92132-92136
92228
92235-92240
A and B Scans
Pachymetry
Corneal Topography
Sensorimotor exam
Visual Field exams
Scanning Laser
Remote imagining-retinal
FA
92250
92265-92275
92283
92284
92285
92286
Fundus photos
Oculoelectromyography
Color vision
Dark adaptation
External photos
Spectular Microscopy
Question 8
Keratoconus Contact Lenses
 I finally had a patient with keratoconus that
the insurance company paid for the visit with
the new code.
The problem was that the carrier did not pay
for the contact and said it is not the patient’s
responsibility.
What can I do?
Question 8
Keratoconus Contact Lenses
 92072
 92071
 HCPCS code options
 Private coverage options
 Medicare options-DMERC
92072
 CPT® Fitting of a contact lens for management of
keratoconus, initial fitting.
 For subsequent fittings, please use either the 9921X
or 9201X codes.
 Report materials in addition to this code, using
either 99070 or the appropriate HCPCS Level II
material code.
92072
 The follow up for the contact lens fitting
would be billed with E&M codes.
 Once the initial contact lens fitting is
complete, 92072 cannot be used again after
this initial fitting. If the keratoconus patient
needed to be treated (fit) again the fitting
92072 would not be used, but instead use an
E&M code and 92310 for the fitting.
92071
 CPT® Fitting of a contact lens for treatment of
ocular surface disease
 Report materials in addition to this code, using
either 99070 or the appropriate HCPCS Level II
material code.
 This is the appropriate code to use for fitting a
bandage contact lens.
92071
 The 92071 code would be used when a patient
has a traumatic injury (abrasion) or another
corneal disorder such as a recurrent corneal
erosion, filamentary keratitis or bullous
keratopathy. The patient or payer would be
billed for the appropriate office visit code,
either a 92000 or 99000 code and the 92071
code for the treatment with the bandage
contact lens.
92071
 The provider may also use a bandage contact
lens after the removal of a corneal foreign
body (65222). In this case the 92071 code can
be billed as a bandage, but some payers will
deny the 92071 because the 65222 is valued
with a wound dressing included in the
payment for the foreign body removal.
Question 9
ICD-10-CM Revisited
 I keep seeing these webinars and
articles about ICD-10-CM.
If I only see regular patients, do I need
to worry about this?
Question 9
ICD-10-CM Revisited
 Federal Law
 AOA Eye-learn
 Vision Plans and coding
 EHR Vendors
 CMS website
 CDC ICD-10-CM website
Z-Codes
 Z01.00 Encounter for examination of eyes and vision
without abnormal findings
 Encounter for examination of eyes and vision NOS
 Z01.01 Encounter for examination of eyes and vision
with abnormal findings
 Use Additional: code to identify abnormal findings
Z-Codes-Examples
 Z01.01 Encounter for examination of eyes and vision
with abnormal findings
 Use Additional: code to identify abnormal findings
 H40.053 Ocular hypertension, bilateral
 H25.13 Age-related nuclear cataract, bilateral
 H52.13 Myopia, bilateral ??
ICD-10-CM Resources
American Optometric Association
www.aoa.org/coding
CDC ICD-10-CM Official USA site
http://www.cdc.gov/nchs/icd/icd10cm.htm
2014 release of ICD-10-CM at bottom of page has all the downloads
ICD-10-CM Guidelines [PDF - 512 KB]
ICD-10-CM PDF Format
ICD-10-CM List of codes and Descriptions (updated 7/3/2013)
CMS ICD-10-CM information
https://www.cms.gov/Medicare/Coding/ICD10/index.html
X World Health X but Use for general training only
http://apps.who.int/classifications/apps/icd/icd10training
Question 10
Non Covered Procedures
 My doctor went to a lecture recently and
told us we can be charging patients for
photography of the cornea for our dry eye
patients.
When we do, the insurance company
keeps denying.
Can you help?
Question 10
Non Covered Procedures
 Anterior Segment imaging –spectral microscopy
 92286
 External Ocular Photography
 92285
 Medical Necessity
 LCD vs. CPB
 Glaucoma Suspect
 Macular Drusen
0330T
 digital interferometry, an eye tear film imaging
method used to assess the lipid layer of the tear film
of the eye in order to measure the thickness of the
layer
 Category III code is usually not reimbursable by third
party payers but the filing of the charges allows the
CPT® editorial panel to gauge the frequency of use
Medical Necessity
 A service that appears to meet the technical
requirements for coverage may be excluded if
that service:
 not generally accepted as safe and effective
 not supported in peer-reviewed medical literature
 not medically necessary in a specific case, or for a
specific medical diagnosis
 furnished at a level, duration, dosage or frequency
not appropriate for a specific patient or clinical
condition
Medical Necessity
 not furnished in manner consistent with standards of care
 not furnished in appropriate medical setting (place of
service)
 furnished in manner primarily for patient/provider
convenience
 device not approved by FDA or not included in an FDA trial
 test or service considered obsolete by the medical
community, and replaced by more efficacious services
Just because you get paid
doesn’t make it right
 Resources
 Medicare Carrier
 CMS
 CCI edits
 Private carrier guidance
 Ask the Coding Experts
 AOA Coding Today
 State Association Third Party Center
Finally
Any last questions?
 All you coding issues are solved! Right!
RIGHT?????
THANK YOU