Transcript DEALING WITH COMMON FRUSTRATIONS FOR THE …

CODING & BILLING: A PRACTICE
LIFELINE
ELAINE SCHMIDT, CPC,
CPO-C, OCS
1
DISCLAIMER


This information is current as to the
time it was prepared and
reasonable effort was made to
assure accuracy. There is no
guarantee of being completely
error-free.
This presentation is intended to be
a tool to assist and guide
understanding.
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IMPORTANT TIDBIT
Because our talents/functions within our
practices are so vital it is important to pay
attention to detail, including gathering
information.
 WHENEVER you call/talk to ANY insurance
entity or person regarding claims or general
information:
ALWAYS get the individual’s name along with
the date you made the call. – This will provide
you with a “history” & hold that individual
accountable for their information provided 4
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FRAUD VS ABUSE - FRAUD
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FRAUD: The INTENTIONAL deception or
misrepresentation that an individual
knows to be false or does not believe to be
true and makes, knowing the deception
could result in some unauthorized benefit
to himself/herself or some other person.
For example:
-billing for tests not performed
-billing higher level of service than
performed
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FRAUD VS ABUSE - ABUSE
ABUSE: Practices of providers, physicians, or
suppliers of service which, although not
usually considered fraudulent, are
inconsistent with accepted sound medical,
business, or fiscal practices, directly or
indirectly resulting in unnecessary costs to
the Medicare (and other carriers) program,
improper reimbursement, or program
reimbursement for services which fail to meet
professionally recognized standards of care or
which are medically unnecessary.
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NEW VS ESTABLISHED- CPT 2013
New Patient: one who is receiving face-toface care from a provider or another
physician of the exact same specialty and
subspecialty who belongs to the same group
PRACTICE for the 1st time in 3 years
Fees should be higher for new patient
services due to gathering new/updated history
The allowable in most cases is higher for a new
patient. More work is involved in
getting/gathering history data
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“NO” to RULE OUT CODES
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Rule Out codes are NOT allowed
Wording such as “R/O, suspect, looks like,
appears to be, possible, questionable, still to
be determined” are warning signs.
In lieu of no confirmed problem or definitive
Dx, the signs & symptoms under
investigation must be coded to support
medical necessity
Get clarification from the doctor, or you
MUST code according to signs and symptoms
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Reason for Visit
The patient’s chief complaint (CC) or reason
for visit drives the diagnosis coding for the
encounter.
 Sometimes a complaint/problem is not
mentioned by the patient until a particular
question is asked; hence the need for a good
history.
Consider coverage, ask the right questions, be
mindful of previous diagnosis or if a new
patient
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Right Questions
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Patients will often give the doctor more
specific/pertinent information than to the
screener
Learn to ask lifestyle questions that prompt
the patient to be more informative that may
uncover a medical complaint
For example: Instead of asking “are you
having any problems?” ask if the patient has
experienced any blurred vision, eye
irritation, tearing – then expand….
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Expand

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What time of day do you notice this; what
are you doing when you notice this,
driving, reading, etc; how severe is the
(symptom). This is a more open form of
communication between the screener and
the patient
Optometry often is lacking in history
documentation, so obtaining this
information is important
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92004, 92014
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General Ophthalmological Service,
Comprehensive – one or more visits (per
CPT)
If the patient comes in for exam one day but
the dilation is performed on a later (ie,
continued) date, there is NOT an additional
charge. It is a continuance of the
comprehensive service.
This should be clearly documented in the
patient’s record
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COMPREHENSIVE
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General evaluation of the complete visual
system. The comprehensive services
constitute a single service entity but need not
be performed at one session
Includes history, general medical
observation, external and ophthalmoscopic
examinations, gross visual fields and basic
sensorimotor examination. Often includes, as
indicated: biomicroscopy, examination with
cycloplegia or mydriasis and tonometry
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Example

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
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COMPREHENSIVE
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The comprehensive exam always
includes initiation of diagnostic and
treatment programs
Such as: prescription of medication,
arranging for special
ophthalmological diagnostic and
treatment services, consultations,
laboratory procedures and
radiological services
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92004, 92014 comprehensive
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AMA CPT definition states mydriasis
(dilation), often includes…
If dilation is contra-indicated or
refused, it needs to be documented
in the patient record
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92002, 92012 - Intermediate
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Ophthalmological service: medical
examination and evaluation with initiation of
diagnostic and treatment program,
intermediate
States may include mydriasis
Fewer exam elements required
BOTH Intermediate & Comprehensive exams
require “initiation of diagnostic and treatment
program”.
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Example-Intermediate
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Review of history, external examination,
ophthalmoscopy, biomicroscopy for an acute
complicated condition (iritis) not requiring
comprehensive ophthalmological services
Review of interval history, external
examination, ophthalmoscopy, biomicroscopy
and tonometry in established patient with
known cataract not requiring comprehensive
ophthalmological services
All intermediates must include external
examination
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Eye Codes: 92xxx Ophthalmological
Exams
Documentation and coding criteria can vary
from payer to payer
 Some payers will want 92xxxs to be nonmedical
(Medicaid, and some commercials)
Some payers will bundle the refraction in the
exam (not treated as a separate procedure)
-As long your amount billed can be shown as
the total of the exam and refraction in this
situation, an auditor would not have a
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problem

Exams
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Sometimes, we “have to play the game” with
the individual payers.
Even though all are subject to HIPAA rules,
CPT, ICD, and documentation guidelines
(DG); interpretation can be problematic
With some payers, the 99xxx evaluation and
management codes are preferred on medical
claims, even though the 92xxx codes allow
for medical diagnosis codes as well as
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refractive (exception: Medicaid)
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Ophthalmological Tests
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Fundus Photograhy (92250), Visual Fields
(92081-92083), Scanning Laser (92133,
92134), Pachymetry (76514), External Ocular
Photography (92285) and most other
ophthalmological testing is NOT bundled with
the exam and is separately reimbursed.
If your claims are being denied, make sure
your coding is correct and the referring
physician information is entered on the claim
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Multiple Procedure Payment Reduction
(MPPR)1/7/13: Implementation Date
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Applies to the Technical Component (TC) on
Ophthalmologic Procedures (furnished on the
same DOS)
Full payment is made for the TC service with
the highest Medicare Physician Fee Schedule
(MPFS). Payment is made @ 80% for
subsequent TC services; resulting in a 20%
payment reduction
Reflected on the remittance advice (RA)
Applies ONLY to the TC, not the PC
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SEQUESTRATION
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Due to mandatory across-the-board reduction
in Federal spending
A 2% payment reduction will be reflected on
the Medicare RA (after the deductible has
been met)
This results in an additional mandatory PWO;
so is not billable to the patient
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Orders for Tests
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A physician’s order for tests must be part of
the patient’s medical record
The reason for the test must be documented
Interpretation and Report (I&R) is part of the
test procedure (per CPT definition) and must
be included in the documentation. If the I&R
is not documented, the service was not done.
The I&R should address findings, relevant
clinical issues, and comparison of previous
findings
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Co-Pays, Deductibles
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The practice of waiving co-pays and or
deductibles is likely to be a violation of the
OIG (Office of Inspector General) False
Claims Act.
When a co-pay or deductible is waived, the
U&C amount submitted on the claim is not
reflective of what you’re actually receiving for
payment, which is an automatic violation of
OIG and the False Claims Act
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SOCIAL SECURITY ACT
Services to immediate relatives can NOT be
billed to Medicare
 VIOLATION OF THE SOCIAL SECURITY ACT
 Included: husband, wife, natural or adoptive
parent, child and sibling; stepparent,
stepchild, stepbrother, stepsister; in-laws,
father, mother, son, daughter, brother, sister,
grandparent and grandchild; spouse of
grandparent and grandchild.
-Does NOT state you can’t bill the patient – just
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not Medicare

Medicare Coverage
Remember that Medicare coverage is
dependent upon the medical necessity of the
service. Coverage is based on the purpose of
the encounter rather than the ultimate Dx.
 Medical Necessity drives the encounter, not
the amount of documentation
 “Not reasonable & necessary” is the
terminology that replaced “Not medically
necessary”
 There is a difference between ‘non-covered’
and ‘not reasonable & necessary’
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Required to Know

Providers are required to know the
rules and regulations available: CMS
Directives-IOM (internet only
manual), Federal Register, WPS
Medicare published education and
written notices, Medical community
general notices
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IMPORTANT RESOURCES
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What the doctor does clinically must be
translated into claims. CORRECT use of the
following resources is vital
ICD-9-CM: International Classification of
Diseases (9th edition)-Clinical Modification
-will be replaced with ICD-10 October 1, 2014
-diagnosis codes – what the doctor finds
List the principle diagnosis 1st. Other
pertinent diagnosis codes need to be included
on the claim
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RESOURCES, continued
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CPT: Current Procedural Terminology –
Procedure codes; what you do
Includes CPT II – PQRS codes
*Procedure codes must be linked with the
correct diagnosis code (pointers)- One
pointer only per line of service
Logically, list procedure codes in appropriate
order
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RESOURCES, continued
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HPCPS Level II: Healthcare Common
Procedure Coding System – In our world,
these contain the material codes
DGs: 1995 & 1997: Documentation
Guidelines for E&M (evaluation &
management) services- For most ODs, the
1997 DGs are often a better “fit”
Learning to appropriately use and
understand these resources requires study
and time
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Other Medicare Billing
Requirements
Medicare contract requires providers bill the
same for Medicare patients as for private pay
and other insurance coverage
 Same fee for same codes
 Can NOT “accept” insurance only and writeoff the balance
The IOM 100-09 cht 6 section 30.1 states
contractors are not allowed to give coding
advice
*When asking, state: “does your SYSTEM like..
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COMPARATIVE BILLING
REPORT-MEDICARE (J5)
WPS will provide a comparative billing report
 It has to be requested: Send letter of request
to:
WPS Medicare Part B
General Correspondence
PO Box 7238
Madison, WI 53707-7238
*Include individual NPI(s)
*Include range of codes
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Provider IDs
NPI – National Provider Identification number
 (replaced UPIN – unique physician
identification number)
 PTAN – Provider Transaction Access Number
Current legacy provider number
-The NPI replaced the PTAN on claims, BUT is
still required and needed for identification
purposes
The NPI, PTAN and last 5 digits of the TIN
(federal tax ID) are needed when calling
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Medicare

MODIFIERS
24- Unrelated E&M service by the same
physician during post-op period
Ex: Patient in for glaucoma check during the
post-op period.
99xxx-24 with glc dx
Ex: Patient seen for iritis during cataract postop period-WHICH happens to be the 1st day
seen for post-op. (unrelated) [Reminder: the
dates of service will be different]
99213-24
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MODIFIERS
25-Significant, separately identifiable
E&M (or 92xxx) by the same physician
on the same day of the procedure (or
other service)
The physician must indicate that the
E&M is above and beyond the work of
the procedure
The guidelines for -25 usage has
narrowed over time
The modifier will AWAYS be attached to
the Office Visit
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Modifier 25 Example
Patient scheduled for glaucoma OV
 During encounter patient complains
of something poking their eye
 99213-25
365.11
 67820
374.05
The correction for trichiasis (epilation)
is not related to – totally separate
from the encounter for glaucoma
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Modifier 25 Example
Patient exam for ARMD: 92014; during which
patient also complains of eye pain.
 92014-25
362.51 (ARMD)
 65205-RT
930.1 (conjunctival FB)
Patient came in for annual exam for ARMD.
During exam, the FB was discovered and
removed.
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Modifier -25 Not Allowed
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Patient states he has pain in his eye after
playing softball where the wind was blowing
sand. Patient gets grain of sand in
conjunctiva.
An OV would NOT be billed with the surgery
code as the complaint tells “the story”. An OV
would be directly related to the reason for the
surgical procedure; not significantly separate.
-Essentially making it COS
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Modifier 25 & 1 diagnosis
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If substantial, extra work was involved
(above & beyond), an OV would be
appropriate to submit with the surgery
code. Documentation must clearly
indicate the extra work
Examples could include removal of
multiple foreign bodies, difficulty with the
patient, other complicating factors
Be prepared to “defend” your claim, as it
may be initially rejected
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Modifier -26 & TC
-26
Professional Component
 -TC
Technical Component
There are several ophthalmological services
that have both a professional and a technical
component. If the physician performs both
elements, no modifier is used.
However, if just one element is done, or if the
service elements are performed on different
days, then these modifiers are used.
When another provider requests a test, you
submit for the TC only & that provider will
indicate the dx (at the DOS)
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Modifier -26 Professional Component
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Patient needs to have an OCT performed, but
your office does not have the machine. You
have another provider do the scan and that
scan is sent back to your provider to
interpret.
You submit only for the professional
component-billing less than what the global
fee would be
*92133-26
*92135 was replaced by 92133, or 92134 and
is bilateral, not unilateral
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Modifier -TC
Another provider does not have a fundus
camera and needs to have retinal photos
performed on a patient; sends patient to you
 92250-TC (not all insurances consider 92250
bilateral)
You only performed the technical component
and so only submit the TC element. (The TC
component has a higher allowable than the
PC component)
(WPS- 92250-TC $49.24
92250-26 $23.46)
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Modifier -26 & TC
Physician is out of the office the day
visual fields are performed. The
physician does the interpretation &
report (I&R) when she returns.
03/10/13 92083-TC
$65.00
03/17/13 92083-26
$25.00
These 2 billed amounts should equal
the amount you would submit if
both elements were performed at
the same time.
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Payment Modifiers
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When using multiple payment modifiers,
there is a specific order to follow.
1st list any modifier that would justify
reporting two procedures together – such as
59(unbundle such as 92133, 92134 & 92250)
Next, list any modifiers that affect payment –
such as 50 – for example 92225, 92226
Then list any “informational” modifiers such
as RT,LT that do NOT affect reimbursement,
but provide more specific information
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Modifier 22 – Increased Service
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Modifier 22: Increased procedural service
requiring work substantially greater than
typically required
Ex: Removal of a high numbers of foreign
bodies
65222-22-Rt
Need to note “documentation available”*
Patient records will most likely be requested
WPS has a Modifier Documentation Form 50
Modifier 52-Reduced Service
Modifier -52 is used to reflect less
than the usual amount of work
performed.
Visual field is performed on one eye
only. This would be some reduced
work.
92083-52
(Do not submit ½ of your usual fee.
There is a reduction in service, but
the service and the I&R must be
done)

51
52
Test Question
Multi-Doctor Practice
 03/01/13: Dr #1 saw patient for corneal
ulcer (dx: 370.00)
 03/08/13: Dr #2(pt new to her) saw
patient for follow-up AND removed
corneal foreign body (dx: 930.0)
9921X-25 370.00
65222-Rt
930.0
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NCCI Modifier Indicators
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National Correct Coding Initiative (NCCI)
assigns modifier indicators that show what
codes can be unbundled
The modifier indicator “0” means you may
NOT use any modifier to unbundle codes
under any circumstances
The “1” indicator allows the use of an
appropriate modifier in some situations to
unbundle the edit and receive payment for
both codes (ex- 92133, OR 92134 & 92250)
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CCI-Correct Coding Initiative
Code pair
 Column 1 = comprehensive element
 Column 2 = component (of the
comprehensive)
 Some codes are bundled and cannot be
unbundled; others can be - given the
right circumstance
*When the unbundling modifier (59) is
used, it ALWAYS is appended to the
column 2 procedure code
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CCI & RVU
The RVU (relative value unit) plays a factor
when appending a modifier to a service
 List the highest paying code first
Example: procedures that are “bundled” per
NCCI, but having a modifier indicator of 1
indicating the procedures can be unbundled
with the 59 modifier
The modifier would be appended to the
procedure with the lower RVU
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Modifier 59-Distinct Procedure Service

Modifier -59 is also known as the
“unbundling” code. The OIG looks at
this modifier usage closely. Some
codes are bundled per correct
coding initiative (CCI)-but can be
unbundled when appropriate.
Documentation is very important to
show need to unbundle.
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Modifier 59
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Patient has fundus photography performed for
macular hemorrhage the same day as
scanning laser is performed for glaucoma. In
CCI, these are bundled codes. In this
example, these 2 procedures are performed
for different reasons, allowing reimbursement
for both services.
92250-59 (FP)
92133 (SL)
362.81 (Mac Hem)
365.11 (POAG)
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Modifier 79
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-79 Unrelated procedure or service by the
same physician during the post-op period
Ex: Co-management of the 2nd cataract
surgery during the 90 days of the 1st eye
Ex: Epilation – 67820 performed during global
Ophthalmological tests unrelated to the
surgery performed during the global would
not require the 79 modifier
59
Modifier 24-Unrelated E&M or OV
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-24 Unrelated E&M Service by the same
physician during a postop period
(would also include 92xxx procedures)
Ex: During cataract comanagment global;
the patient is seen for allergic conjunctivitis
(372.14)
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Modifier 51 – Multiple surgeries
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WPS will apply the multiple surgery modifier
which is seen on the RA
Example: PPs (68761-closure, lacrimal punta
by plug)
68761 LT E1
68761 LT E2 (51-added by WPS)
68761 RT E3 (51 added)
68761 RT E4 (51 added)
The 1st line of svc was fully @ fee schedule
Lines 2,3,4 were allowed @ 50% fee schedule
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Modifier 99-Multiple Modifiers
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The HCFA 1500 will accept 4 sets of
modifiers; but you could use the -99 to
reflect multiple modifiers
Overflow modifier
Ex: Co-mgmt, 2nd eye during 1st eye global
66984-55-99
In the narrative field you would detail the
“rest of the picture” ie, 79, rt or lt
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Modifier GW
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GW is the Hospice modifier. States
that the service you’re
providing/submitting is not related
to Hospice care. (Often we find this
out after the claim comes back
denied on the remit)
92004-GW
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Modifier Q6-Locum Tenens
-Q6 Locum Tenens: Service furnished by
a locum tenens physician.
Used by a temporary fill-in physician. This
cannot exceed beyond a continual 60
days.
Some carriers require the NPI of the Locum
Tenens doctor be included in box 23 of
the HCFA 1500.
It is also recommended that these claims
be “kept track of” in case of an audit.

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Q6 Locum Tenens


Append Q6 to each procedure code
(line of service) submitted
Submit under regular physician’s
name/NPI
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Modifier GA

GA indicates you have a signed waiver of
liability. If the patient did NOT sign a waiver
(usually involving the ABN or other waiver of
liability) at the time of service - you CANNOT
use the GA modifier. *
*GA could be used in the case of a “valid” but
unsigned ABN. Document who refused as well
as being signed by the ABN presenter and a
witness
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Modifier GZ, GY


GZ - The provider expects a medical
necessity denial; but did NOT complete
and provide an ABN at the date of
service. (No ABN executed)
GY – Item or service is statutorily
excluded, or does NOT meet the
definition of a Medicare benefit. (This
modifier is optional) Possible usage on
refraction if patient wants it filed)
68
Modifier EY, KX
EY- (for DME) NO physician order-use ABN-ONLY 5
required items for Noridian.
Anti-reflective coating-V2750
Tints – V2745 (includes) V2744-photochromatic)
Over-size – V2780
*Polycarb – V2784 (medical necessity)
KX-(DME) Medically necessary-EXCLUDING UV
V2755 which is defined as medically appropriate &
necessary (ex: tints)
Ex: V2745 KX Rt Lt (tint prescribed by physician)
*Functioning vision only in 1 eye
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Bilateral Procedure Indicators


Medicare assigns Bilateral Indicators
to all CPT codes to indicate whether
the code is subject to a payment
adjustment if reported bilaterally.
These indicators state if you have
the option of reporting a code
bilaterally or unilaterally.
These indicators or “0”, “1”, “2”,
“3”, or “9”
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Bilateral Indicator “0”
The “0” means the bilateral
adjustment does NOT apply
because the code descriptor
specifically states that it is a
unilateral procedure.
92311, 92313, 92315, 92317, 92325,
92326,92499 are not to be reported
bilaterally
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Bilateral Indicator “1”
“1” Bilateral Indicator means the code
may be reported bilaterally
65205, 65210, 65220, 65222, 65430,
65435, 67820, 67938, 68761,
68801 can be reported bilaterally.
If reported bilaterally; the multiple
surgery guidelines apply
150% of allowed
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Bilateral Indicator “2”
The bilateral indicator “2” states codes are NOT
reported bilaterally.
76514, 76516, 76519, *76549-TC, 92020,
92060, 92065, 92081, 92082, 92083, 92100,
92120, 92130, *92132, 92133, 92134,
92136, *92136-TC, 92140, **92250, 92260,
92265, 92270, 92275, 92283, 92284, 92285,
92286, 92287, 92312, 92316
(*Exception: 76519-26 and 92136-26 which
have the indicator “3”)
**BSBC issue
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Bilateral Indicator “3”
Bilateral Indicator “3” states the codes may
be reported bilaterally
76510, 76511, 76512, 76513, 76519-26,
76529, 92071, 92072, 92136-26, 92225,
92226, 92230, 92235, 92240
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Bilateral Indicator ‘9”
Indicator “9” states the bilateral concept does
NOT apply.
92015, 92310, 92314, 92340, 92341, 92342,
92352, 92353, 92354, 92355, 92358, 92370,
92371
(Most of the codes marked indicated with “9”
are for contact lens fitting)
*The bilateral indicators for all CPT codes are in
Column T of the Physician Fee Schedule
Database File:
www.cms.hhs.gov/PhysicianFeeSched
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Medicare Coverage

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
Remember that Medicare coverage is
dependent upon the medical necessity of the
service. Coverage is based on the purpose of
the encounter rather than the ultimate
diagnosis.
Medical Necessity drives the encounter, not
the amount of documentation.
The Medicare Part B deductible for 2014 is
$147; no change from 2013
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LAW
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Providers are required by law to file Medicare
claims, unless the provider opted out.
If you opt out of Medicare, you will not see
Medicare patients
Exception: If a Medicare patient specifically
states he/she does NOT want the claim filed
to Medicare and is willing to pay U&C
charge(s) out of pocket
(this is according to the AOA coding experts)
(our office will document and get a signature79
even though not legally required)
General Claim Guidelines


Procedure code line items are matched with
the appropriate diagnosis code (field 19 on
the HCFA) with only one Dx per service line
Often there will be multiple diagnosis codes
appropriate to the overall encounter; the
principle diagnosis code (reason for
encounter) is to be listed 1st. (Typically
relates back to the CC (chief complaint)
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Multiple E&M Service-Same Day


Medicare allows for one E&M visit
per day by the same provider or
member of the same group, same
specialty
UNLESS…..
Exception: Possible -25 Modifier


If same day visits were unrelated
and could NOT have been provided
during the same encounter, both
would (should) be allowed.
Documentation must support the
need.
2nd service may deny requiring a
redetermination
Multiple Encounter, same day




Patient 1st encounter, AM, 92012 with Dx of
375.15-dry eye
2nd encounter later same day got different
onset episode of visual aura lasting 20
minutes. 99213 with Dx of 346.80ophthalmic migraine.
Attach the 25 modifier to the 2nd service.
Unrelated to 1st encounter and was not
present at the time of the 1st encounter
In narrative field state “documentation
83
available upon request
Corneal FB OU




65222 is unilateral, so for corneal
FBs rt, lt, submit as 2 lines of
service.
65222 Rt
930.0
65222 Lt
930.0
Multiple surgery guidelines will
apply (2nd service will be allowed at
50 % of the allowable)
84
Foreign Bodies; Two Sites
If a patient has foreign bodies,
same eye, one in the conjunctiva
and one in the cornea; both are
eligible for reimbursement. These
two surgery codes are not bundled
as they involve different parts of the
eye.
85
FBs – 2 sites
65222 (corneal FB removal) Rt
930.0
 65210 (conjunctival FB removal) Rt
930.1
The 2nd surgery will be allowed at
50%

*some carriers may still require the
59 modifier
86
Conjunctival Concretions




Technically considered Foreign Bodies
Dx: 372.54-conjunctival concretions
65210 – removal FB, external eye;
conjunctival embedded (includes
concretions), subconjunctival concretions
Just because it’s coded FBR, do not state the
service is due to an accident
87
88
Co-Management Modifier 55


Claims for co-management have had
issues for an ongoing time. It is
complicated by the fact that some
carriers want certain information and
others want different information. Also,
the global period for major surgeries is
not the same for all carriers.
One of the most common problems is the
relinquish date. (Remember, relinquish
refers to the final date of the post-op
care; 90th day)
89
Case by Case



Co-management should always be
determined on a case by case basis,
beginning with needs/wants of the
patient.
Should NOT be prearranged
Medicare Law on co-management
billing includes a written transfer of
care agreement
90
Communication is Key








Prior to surgery:
-referral request form
-pertinent patient notes
-consent for co-management
After surgery:
-transfer of care
-operative notes
-post-operative notes
91
Post-Op Care
WPS Medicare has a link that calculates
the relinquish date:
www.wpsmedicare.com/j5macpartb
Resources-calculators

-Fast & Easy
92
Post-Op Care
Post-op begins the 1st day after surgery-not
the surgery date (even though the surgery
date is the date of service)
Some payers’ policies state the post-op count
begins the day of surgery
 Keep in mind, carriers are not uniform in how
they want these claims.
Some carriers don’t want the relinquish date.
They want date you accepted care and how
many days of care. Others want the date you
accept care and the relinquish date with no
mention of # of days of care.
93
Post-Op Care
Still other carriers like BCBSKS allow
for only 42 days of post-op care.
In the narrative field BCBSKS now
also requires the accept care date
and the relinquish date.
Most all carriers want the DOS to be
the surgery date.
94
Dry Eyes
Patient complains of dry eyes, but
the physician does NOT have clinical
findings to support the dry eye
diagnosis of 375.15
Code per complaint which could be
eye pain (379.91), red eye
(379.93), or Epiphora (375.20)

95
Scanning Laser
92135 was replaced with 2 new codes;
92133, 92134
 {*92132 – Anterior – not payable by WPS }
 92133 – Posterior, Optic Nerve
 92134 – Posterior, Retina
Unilateral or Bilateral, so NOT billable per eye.
92133, 92134 can NOT be billed together on
the same date of service-regardless of the
diagnosis
*Draft Policy-now approved; effective date ? 96

CPT


Whenever CPT states “unilateral or
bilateral”, it effectively means
already bilateral
Can not submit per eye
97
Serial Tonometry - 92100


Serial Tonometry requires multiple
pressure checks over the course of
the day, not just a couple in an
hour
Normally performed because of
serious IOP
98
Extended, Subsequent
Opthalmoscopy
92225: Initial ophthalmoscopy (does
require drawing)
 92226: Subsequent-If patient is seen
back for a repeat ophthalmoscopy with
the same diagnosis, use 92226.
 (even if a year later)
A different diagnosis is what determines
initial or subsequent
(Unilateral)

99
Epilation
Epilation – 67820 is defined per
eye, not per eyelid.
 150% if reported bilaterally
(multiple surgery guidelines)

67820 has been reported several
different ways in the past.
Per lash, per lid, etc
100
101
Drug Effects

If you are monitoring a patient who,
(for example) is currently using a
high risk medication that affects the
ocular system use the diagnosis
V58.69 - long-term-current use of
high risk medication. If the patient
has completed the course of
treatment for the drug, then use
V67.51-completion of treatment for
high risk medication.
102
Prolonged Service
99354 Prolonged Service requires a minimally
additional 30 minutes beyond what the
service would normally be. It must be face to
face with the physician. It is billed in addition
to the E&M original encounter.
99213
99354
(99355 for each 30 minutes after 99354)
Your documentation must support the need for
the prolonged service. Record the face to face
time.
103

Prolonged Service


You do NOT have to bill the highest
level of E&M to additionally use the
prolonged service procedure code.
The level of service for the
encounter is based on history,
exam, and medical decision making.
104
105
Time as Key Element



Per CPT; when counseling and/or coordination
of care DOMINATES more than 50% of 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.
Time must be documented.
Document total time spent on encounter,
time spent on counseling & coordination of
care or %, and reason or topic of counseling
106
CoC
A-Scans 76519



Ophthalmic biometry by ultrasound
echography, A-scan; with
intraocular lens power calculation.
The TC has modifier indicator 2
stating the code is inherently
bilateral*
The professional component (26)
has modifier indicator 3 meaning
the code is inherently unilateral
107
A-Scan
When you report 76519 as a global code
(without modifiers), you’re stating both the
technical and professional components were
performed.
 If you calculate IOL power in both eyes, code
the TC & PC components separately:
76519-TC for bilateral technical component
76519-26-50 for bilateral professional
component (only the PC can be submitted
with the 50 modifier)

108
Punctum Plugs





68761 – Closure of the lacrimal punctum; by
plug, each
10 day global
Same surgery code used for both temporary
and permanent plugs
Some carriers do not like modifier -51;
making reporting more than 2 closures
difficult. E codes to help define can be used.
E1 UL, E2 LL, E3 UR, E4 LR
109
Punctum Plugs
Supply as much information in narrative as
possible
 E codes not universally accepted
 Most commonly the 2 inferior puncta are
involved.
Submit as 68761-50 or
68761 Rt E4
68761 Lt E2
If the encounter is only for PPs, an office visit
110
can NOT be additionally submitted

Punctum Plugs
Submitting for each puncta as separate line
item may simplify claim processing
Medicare considers PP removal part of the
global package-even though outside the 10
days.
Option:
Submit with the appropriate level E&M code
using signs and symptoms
111
112
New Therapeutic Contact Lens
Fitting Codes





Effective January 1, 2012, 92070 was retired
and replaced with 2 new codes, 92071 and
92072.
These codes are unilateral
(They have NOT been without issue)
92071 is the fitting of contact lens for
treatment of ocular surface disease. – An
example would be for corneal abrasions
92071 most nearly replaces 92070
113
92071



Often best utilized for a bandage
contact lens fit
If a non-revenue contact lens
(diagnostic or trial) is used, it is not
appropriate to bill for the contact
lens
If appropriate, could bill with an
E&M or 92xxx
114
92072-Therapeutic CL fit for
Keratoconus





92072 is the fitting of contact lens for
management of keratoconus, initial fitting.
When subsequent follow-up visits are
required, use an appropriate level E&M or
general ophthalmological code.
3 diagnosis codes
-371.60 – unspecified
-371.61 – stable
-371.62 – acute, hydrops
115
92072






The supplies are NOT included in
the service, and are to be billed
separately with the V code that best
matches
Most common
-V2513 – GP, extended wear
V2530 – Hybrid
V2531 – GP, scleral
V2599 – Other type
116
Keratoconus
371.60 unspecified
371.61 stable
371.62 acute, hydrops
Post-Keratoplasy V42.5 – organ or
tissue replaced by transplant,
cornea
367.22 Irregular astigmatism
117
118
Diabetes-Ophthalmic Manifestation



ICD-9 states that you must first
code diabetes (principle Dx)-not all
carriers follow correct coding
250.5X would be the principle Dx
with the manifestation as the 2nd Dx
-ICD-10 will greatly simplify this
119
Diabetes-Ophthalmic Manifestation





Blindness
369-369.9
Cataract
366.41
Glaucoma
365.44
Macular Edema 362.07
Retinopathy
362.01-362.07
120
Example DM & BDR
Service line 1: 250.5x – diabetes with
ophthalmic manifestation
Service line 2: 362.01 – background diabetic
retinopathy
The BDR is the manifestation of the diabetes
ICD states: Must first code diabetes
*That being said; not all payers follow this
correct coding example
121
DM, Retinopathy Example
Medical record states BDR – 362.01
The retinopathy is a manifestation of
diabetes – 250.5X
Sample claim: Principle Dx: 250.5X,
2ndary Dx: 362.01
99214
250.5X
92250
362.01
Some carriers allow just the DM Dx, for the
FPs, but DR more accurately “tells the
story”
122

Glaucoma





Several new glaucoma diagnosis codes were
implemented January 1, 2012:
365.01: open angle with borderline findings,
low risk; open angle, low risk
365.02: anatomical narrow angle includes
added language “Primary angle closure
suspect”
365.05: Open angle with borderline findings,
high risk
365.06” Primary angle closure without
123
glaucoma damage
Glaucoma Stage Codes
365.70: Unspecified Stage Glaucoma
 365.71: Mild or Early Stage Glaucoma
 365.72: Moderate Stage Glaucoma
 365.73: Severe Stage Glaucoma
 365.74: Indeterminate Stage Glaucoma
Use the appropriate Stage code for the patient’s
worst eye

124
Glaucoma Stage Codes, con’t


The Stage codes are 2ndary and coded after
the actual glaucoma diagnosis code. Stage
codes can NOT be used without the primary
glaucoma diagnosis
The recommendation is not using either
365.70 or 365.74 as they are defined as
“unspecified” or “indeterminate”. Code the
specific stage of glaucoma
125
Glaucoma Stages
The following Glaucoma codes require one of
the stage codes:
365.10, 365.11, 365.12, 365.13,(open angle
GLC) 365.20, 365.23,(angle closure GLC)
365.31,(corticosteroid included GLC)
365.52,(GLC associated with disorders of the
crystalline lens) 365.62, 365.63, and 365.65,
(GLC associated with other ocular disorders)
 Do NOT report with suspect codes: 365.00365.06

126
Glaucoma Screenings
G0117
High-risk patients, every 12 months
Patients with a family history of glaucoma,
diabetes mellitus, blacks age 50 and
older, Hispanics age 65 and older
*dilated eye exam with an IOP
measurement,
*direct ophthalmoscopy exam, or slit-lamp
biomicroscopic exam
*Must use diagnosis V80.1

127
Glaucoma Screening VS OV



----SO---Consider if submitting an E&M or 92xxx
exam code is more appropriate than
G0117
Other ophthalmological services such as
VFs and scanning laser can NOT be
submitted with G0117, G0118 – but are
allowed with E&M or 92xxx
ophthalmological codes
128
129
S0620, S0621 (Just say ‘NO’)
S0620-New Patient
S0621-Established Patient
Non-medical eye exam
-Seeing some re-emergence
Potential Risks-no accepted definition
as to level of service
130
S0620, S0621
CPT has detailed written definitions
for exam codes
S0 codes bundle refraction with the
rest of an “undefined” exam
Not in agreement or in compliance
with HIPAA law
131
INSURANCE EQUITY STATUTE



Many states have a law that
requires insurance companies
reimburse optometrists for services
covered under their scope of
practice
Must be services that are covered
under the insurance company’s
policy
Does not include ERISA plans as
federal law preempts state law
132
Insurance Equity



If an insurance company rejects a
claim from an OD for a service that
is covered under that company’s
plan a letter should be sent to that
company
You will need to reference your
state law/Statute # in your letter
Contact your state organization for
further information
133
Kansas Insurance Commissioner
Google Kansas Insurance
Commissioner
 www.ksinsurance.or
Links, phone number, and address
supplied

134
Per HIPAA:
Claims submitted using the 3 nationally
recognized criteria: CPT, ICD, and DGs
(documentation guidelines) cannot be
rejected
Providers as well as insurance companies must
follow these national standards (rules)
Insist insurance companies recognize full
scope of practice
135
Considerations:




-Refraction (92015) is NOT content of service
of the OV or any other service (separate code
as of 1992)
Typically, a re-pricer tries to negotiate a
lower reimbursement to the provider
Don’t sign a contract without having the fee
schedule
Have payers send you the current contractRelate the them you are reviewing the
contract, including the fee schedule
136
Illegible Provider Signature?



Log provider signature with date
prior to requested documentation
Printed name, then signature
Will have for proof when
documentation is requested
137
Turning Over Records


Releasing a patient’s medical record
is determined according to your
state regulations.
In many states, you canNOT hold a
patient’s medical record for ransom
even if there is an old or large (or
both) balance owed to the practice
138
Option
Prescribers may require a patient to pay for the
exam, fitting and evaluation before giving the
patient a copy of contact lens prescription,
but only if the prescriber also requires
immediate payment from patients whose
exams reveal no need for glasses, contact
lenses, or other corrective eye care products.
Proof of valid insurance coverage counts as
payment for purposes of this requirement
http://business.ftc.gov/documents/bus62contact-lens-rule-guide-prescribers-and139
sellers
Keeping Patient Records



Most carriers have requirements as
to how long you must keep medical
records.
Check with your carriers to find out
those requirements.
(For example, WPS Medicare says
you must keep patient medical
records for 6 years plus 3 months
after Medicare has processed)
140
141
Medicare, Medicaid Overpayments
Medicare and Medicaid overpayments
must be returned/reported within
60 days - or face TRIPLE penalties.
Not reporting/returning
overpayments is a form of
fraudulent billing.
Per AOA NEWS May 24, 2010
142
143
ABN FORM





ABN: Advance Beneficiary Notice of
Noncoverage
Used to indicate procedures/services/items
believed not to be covered
Must be date specific
Never have the patient sign a blank ABN
The ABN has had slight modifications. The
current/required form is CMS-R-131 (03/11)
144
ABN

The provider (or representative of)
is required to fill out the notifier,
patient name, identifier, service &
why believed potential noncoverage and cost
145
ABN
The patient will select option 1, 2, or 3
 Option 1 says the patient informed of noncoverage, but still wants services/items
submitted
 Option 2 says patient informed, items
wanted, do NOT have to submit
 Option 3 says patient does not want
items/services
(option 3 is not likely to be applicable/used)
The patient must sign & date prior to service

146
30 Supplier Standards





30 Supplier standards for DME claims
Federal requirement – not an options
Indicates the provider adheres to government
standards, regulations
The patient must sign and date
Used at the time of order
147
Proof of Delivery-for Durable Medical
Equipment (DME)





Proof of Delivery (Item 12 on the 30 Supplier
Standards) is used for DME claims
Although not an individual form, this is a
federal requirement
The patient must sign and date when glasses
or DME received
Keep for 7 years
The date signed & received (dispensed) is the
service date for the materials (Medicare DME)
148
UPDATE – New CMS Claim Form





CMS 1500 revised to Version 02/12
-could use effect January 6, 2014
-MANDATORY use April 1, 2014
Accomodate ICD-10-CM
Expands the number of possible diagnoses
codes on a claim to 12; *using letters A-L as
pointers – NOT numbers

149
CMS Form Qualifiers
New qualifiers are used to indicate if the
provider is ordering, referring, or
supervising; revising field 17 – referring
provider
 DN – Referring Provider
 DK – Ordering Provider
 DQ – Supervising Provider
-The qualifier is entered to the left of the
dotted vertical line on item 17

150
UPDATES





Beginning February 3, 2014, WPS Medicare
(J5 & J8) has a single toll-free number to
respond to Medicare needs
J5: 866-518-3285
J8: 866-234-7331
-It will guide you to Customer Service,
Appeals, Electronic Data Interchange (EDI),
Reopenings, and Provider Enrollment
-It will NOT include EFT, IVR, and Payment
Recovery
151
UPDATE – New Category III CPT
Code – 0341T





Pupillometry: 0341T
Quantitative pupillometry with interpretation
and report, unilateral or bilateral
There are hand held digital & standardized
measures available (a millimeter ruler is not
adequate)
It is not in the 2014 CPT but still valid and
will be in 2015 CPT
Temporary Codes are the 1st step toward a
permanent code
152
CAUTION:
Under-coding is just as bad as overcoding
Could be viewed as a form of
kickback
153
FINAL THOUGHTS
We play a critical role within the dynamics of
our offices
We are not alone in our frustrations,
confusions, challenges, and anxieties (even
though these things may leave us
delusional)
Celebrate our victories and take pride in them
Remember: “What lies behind us and what
lies before us are small matters compared
to what lies within us.”-RW Emerson
154
155