Key Elements to Effective Medical Eye Care Coding and Billing

1

When a Patient Enters Your Practice

What does the patient want?

What does the patient need?

What do you perform or provide for the patient?

What are the patient expectations? What would you want if you were the patient?

2

Obtaining Third Party Information

Seek information as soon as possible in the process Don’t expect the patient to know their plan or coverage Be familiar with your local area companies and their plan coverage  Telephone-appointment scheduling  In person-copies of vision and/or medical plan cards and/or plan information pages 3

Obtaining Third Party Information

cont.

Verify coverage (obtain authorization as soon as possible) Depending on the nature of the visit, determine if medical plan deductibles have been met and determine any co payments Doctor and staff must exhibit confidence about the practice’s role in medical eye care and medical plan activities 4

Advance Beneficiary Notice (ABN)

 First issued October 1, 2002  Used for services and materials  Not required for items excluded by statute, such as refraction, contact lenses not covered and eyeglasses not covered  Submit claims with -GA modifier  New ABN @ www.cms.hhs.gov/bni 5

Health Care Procedural Coding System (HCPCS)

Level I HCPCS  CPT-4 Procedure codes Level II HCPCS  Alpha-numeric codes to allow billing of supplies, such as V2200 bifocal lenses Level III HCPCS  Local codes 6

ICD Diagnosis Codes

International Classification of Diseases (ICD)

7

Diagnosis Codes

 Developed and controlled by the World Health Organization (WHO)  The key to payment of billed procedure codes  Linked codes to procedure codes  Valuable to payers to track conditions and statistics  Change to alpha-numeric ICD-10 in 2013 8

Diagnosis Codes

 HHS has established that ICD-10 codes be used by health care providers to report diagnosis with procedures beginning October 1, 2013  ICD-9 contains 17,000 codes where ICD-10 will increase to 155,000 codes  Introduction to HIPAA 5010 at www.CMS.gov/MLNMattersArticles  AOA Third Party Center will provide educational materials-Be proactive!

9

Glaucoma

H40 H40.0 H40.1 H40.2 H40.3 H40.4 H40.5 H40.6 H40.8 H40.9 Glaucoma

Excludes:

absolute glaucoma (H44.5) congenital glaucoma (Q15.0) traumatic glaucoma due to birth injury (P15.3)

Glaucoma suspect

Ocular hypertension

Primary open-angle glaucoma

Glaucoma (primary)(residual stage): · capsular with pseudoexfoliation of lens · chronic simple · low-tension · pigmentary

Primary angle-closure glaucoma

Angle-closure glaucoma (primary)(residual stage): · acute · chronic · intermittent

Glaucoma secondary to eye trauma

Use additional code, if desired, to identify cause.

Glaucoma secondary to eye inflammation

Use additional code, if desired, to identify cause.

Glaucoma secondary to other eye disorders

Use additional code, if desired, to identify cause.

Glaucoma secondary to drugs

Use additional external cause code (Chapter XX), if desired, to identify drug.

Other glaucoma Glaucoma, unspecified

10

ICD-9 Codes

International Classification of Disease, Ninth Edition Diagnosis Codes Can be a 4 Digit code, however be suspicious  Typically, a 5 Digit Code with a Decimal Point  123.45

 123.4

11

ICD Diagnosis Codes

 List primary diagnosis code first and all other ICD codes after  Use most detailed and specific code(s) possible for each submission      List all pertinent diagnosis for each patient for claims Some medical plans reject refractive diagnosis Most vision plans today DO NOT reject medical diagnosis Many vision plans require the submission of all applicable ICD diagnosis codes for all patients (refractive and medical) Avoid xxx.9 codes whenever possible  Codes may need to be line item specific for procedures linked to different diagnosis 12

ICD Diagnosis Codes

cont.

Verify coverage (obtain authorization as soon as possible)  Vitreous Degeneration  379.2-Disorders of vitreous body  379.21-Vitreous degeneration  379.9-Unspecified disorder of the eye and adnexa 13

V-Diagnosis Codes

    V43.1-Pseudophakia V58.69-Encounter-long-term (current use) of other (high risk) medications V65.5-Person with feared complaint in whom no diagnosis was made V67.51-Follow-up exam following completed treatment with high risk medication(s) 14

V-Diagnosis Codes

cont.

 V71.8-Observation and evaluation for other specified suspected conditions  V72.0-Special examination of eyes and vision  V80.1-Special screening for glaucoma  V80.2-Special screening for other eye conditions 15

Diabetes

Diabetes Mellitus-ICD 250.xx

 250.0_-Diabetes w/o complication or manifestation  250.5_-Diabetes with ophthalmic manifestations  5 th digit  0-Type 2 or unspecified not stated as uncontrolled  1-Type 1-not stated as uncontrolled  2-Type 2 or unspecified uncontrolled  3-Type 1-uncontrolled 16

Diabetic Retinopathy

If diabetic retinopathy is present, appropriate coding is to list 250.5x plus Type of diabetic retinopathy present  362.03-Not otherwise specified (NOS)  362.04-Mild Non-proliferative  362.05-Moderate Non-proliferative  362.06-Severe Non-proliferative  362.07-Diabetic Macular Edema 17

Selecting The Appropriate Procedure Code

Identify appropriate Category of Service Evaluation/Management EM Ophthalmological (must meet requirements and definitions listed)   Determine extent of History Determine extent of Examination  Determine extent of Medical Decision Making “S” Code Consultation   Determine extent of History Determine extent of Examination  Determine extent of Medical Decision Making 18

Utilization Patterns

Medicare-Ophthalmology-2008

CPT 99205 99204 New Patients Level 5 Level 4 Usage 2% 18% 73%* CPT 99215 99214 92014 99213 99203 92004 99202 92012 99201 Level 3 Comp Level 2 Int Level 1 8%* 0% 99212 99211 Est Patients Level 5 Level 4 Comp Level 3 Int Level 2 Usage 1% 49%* 44%* 5% Level 1 0% 19 * Combined utilization of E/M and Eye Codes

Utilization Patterns

Medicare-Optometry-2008

CPT 99205 99204 New Patients Level 5 Level 4 Usage 1% 14% 99203 92004 99202 92012 99201 Level 3 Comp Level 2 Int Level 1 75%* 9%* 0% CPT 99215 99214 92014 99213 99212 Est Patients Level 5 Level 4 Comp Level 3 Int Level 2 Usage 1% 50%* 42%* 6% 99211 Level 1 0% 20

Utilization Patterns

- Optometry

  New Patient Codes  Combined 92004/99203-75%  92004-65%  99203-10% Established Patient Codes  Combined 92014/99214-50%  92014-41%  99214-9% 21

Develop Your Practice Metrics

Ocular Surface Disease/ Dry Eye

 Reported prevalence in the population = 25-30%  What is your percentage of OSD work-ups and treatment?

 Office service follow-up (99212-99214)  Dilation and irrigation (68801)  Punctal occlusion (68761) 22

Develop Your Practice Metrics

cont.

Glaucoma

 Reported prevalence in the population = 1-3% with some population segments as high as 11.5%  What is your percentage of glaucoma work-ups and treatment?

 Office service follow-up (99212-99214)  Visual field analysis (92083)  Gonioscopy (92020)  Serial tonometry (92100)  Fundus photography (92250)  Scanning laser (92135)  Pachymetry (76514) Decreases 23

Great

Decreases

“The Debate”

Vision Plan or Medical Plan Billing

24

Case Example

Patient presents vision plan card (has PPO Managed Health Care Plan) and is seeking new Rx History and clinical findings reveal: What options for billing exist?

 Ocular Surface Disease that appears inflammatory based  A quality refraction is completed and Rx determined 25

Case Example

cont

.

Option 1 Option 2

 Bill comprehensive examination to Vision Plan  Self-refer/reschedule for OSD work-up  Bill comprehensive examination to PPO  Refraction (92015) to Vision Plan  Self-refer/re-schedule for follow-up to OSD treatment plan 26

Billing Considerations

Is your office a participating provider on the PPO medical plan What were the patient’s expectations entering the office Does the Vision Plan have a primary eye care program to allow extended medical eye services to be billed Is the billing option presented consistent with other payer types in Decreases 27

Plan Will Be Billed

?

Decreases 

The Holder of the Coverage!

28

Billing Considerations

Confidence Increases Communication to Managing the schedule  Explain findings as your clinical tests progress  Stop and recommend course of care as well as coding/billing  Establish expectations for care and schedule  Re-schedule as indicated by condition(s) 29

Unfortunate Example

Monday, May 05, 2008 – xx Dept of Insurance xxxx-area Optometrist Guilty of Insurance Fraud Totaling Nearly $11,500.

xxxx – xxx xxxx, a xxxx-area optometrist investigated by the xx Department of Insurance for insurance fraud, pled no contest today to a Bill of Information charging Him with one count of insurance fraud, a felony of the fifth degree thereby waiving his right to be indicted. xxxx was found guilty of illegally billing insurance entities Anthem, United Health Care and Tricare and fraudulently receiving nearly $11,500 for personal gain.

Department Fraud and Enforcement attorney xxx xxxx served as special prosecutor in the case before the xxxx County Court of Common Pleas. xxxx sentencing hearing is scheduled for June 17 at 10 a.m. He faces a potential prison sentence from six to 12 months.

Decreases some cases, advise the patients that their insurance would not cover this test but that it was important that they have it. The patients would pay him their co-payments as well as the $21. He would only show the co-payments on the insurance submissions then bill the insurers and pocket the money. He would also bill for a bogus mucous membrane test that required a special allergen – which the office did not have – to be inserted into the eye membrane.

xxxx who suspect insurance fraud should call the Departments fraud hotline at 1-800-xxx-xxxx.. 30

Increases Decreases

Medical Eye Care

31

Medical Necessity is:

Medicare:  Services that are proper and needed for the diagnosis or Increases the diagnosis and direct care and treatment of the patient’s medical condition(s), meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or physician.

Other coverage definitions: Decreases  Treatment based on evidence-based medical standards, or the treatment is considered by most physicians in your community to be clinically appropriate 32

What is of Primary Importance for Billing a Medical Visit

A Chief Complaint

33

Chief Complaint

“The coverage of services rendered by a physician is dependent on the Increases patient’s condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye exam with no specific complaint, the expenses for the examination are not covered even though as a result of the examination the doctor discovered a pathological condition .” Decreases

Bottom Line: To qualify for reimbursement, you must establish a link between the chief complaint and the submitted diagnosis

34

Selecting and Using Evaluation/Management (E/M) Codes

35

Elements of E/M Coding

History* Examination* Medical Decision Decreases Counseling * Key Elements Coordination of Care Nature of Presenting Problem Time 36

Time

 “When counseling or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face to face time…), then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members. The extent 37

Typical Times in CPT-4

 99204-45 minutes  99203-30 minutes  99202-20 minutes  99215-40 minutes  99214-25 minutes  99213-15 minutes  99212-10 minutes  99211-5 minutes (Non physician) 38

Documentation Guidelines

  Adds detail to E/M original definitions Increases Need to obtain a copy of 1995 or 1997 Guidelines and be aware of what standards you will be held to  A copy of the 1995 and 1997 guidelines are Decreases http://www.cms.hhs.gov/MLNProducts/downloads/ referenceII.pdf

39

Medical Decision Making

    Minimal-One self-limited or minor problem Low-Two or more self-limited or minor problems; One stable chronic illness; One acute uncomplicated illness or injury-Treatment w/ OTC medication Moderate-One or more chronic illness…; Two or more stable chronic illnesses; Undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury- Treatment w/ prescription medication High-One or more chronic illnesses w/ progression; Acute or chronic illnesses or injuries that pose a threat to life or bodily function; abrupt change to neurological status-Treatment w/ therapy that requires toxicity monitoring 40 Source: 1997 Documentation Guidelines

Consultations

Decreases 41

Consultation Requirements

Consultation …Service Increases whose opinion or advice regarding evaluation and/or management of a specific problem is physician or other appropriate source. Needed elements:  Request  Render Opinion  Report of findings to requesting physician or other source 42

E/M Consultation Codes

The Federal Register, Vol. 74, No. 226 posted

November 25, 2009, contains CMS’ final decision to eliminate both outpatient consultations (99241 – 99245) and inpatient consultations (99251 – 99255) for payment purposes. CMS cites lack of understanding and confusion over their use as the rationale to eliminate them. Physicians should use either evaluation and management (992xx) or ophthalmology (920xx) codes in place of outpatient consultations.

43

Increases

Special Ophthalmological Services

44

Other Specialized Services

92020-Gonioscopy (B) 92081-Visual Field (B) 92082-Visual Field (B) Decreases 92083-Visual Field (B) 92100-Serial Tonometry (B) Must use multiple readings (3 minimum) in the same 24-hour period 45

Other Specialized Services

cont.

92135-Scanning computerized imaging with interpretation and report (U)  Bundled by many payers with 92250 or 92083 if billed at same session (use an ABN!)  Not truly indicated in advanced disease 92225-Ophthalmoscopy extended, with retinal drawing, interpretation and report, initial 92226-Ophthalmoscopy, subsequent (U) 46

Other Specialized Services

cont.

92250-Fundus photography w/ 92283-Color vision examination, extended (B) 92285-External ocular photography w/ interpretation and report for documentation of medical progress (B) 47

OCT-Anterior Segment

Category III Code

 0187T-Scanning computerized ophthalmic diagnostic imaging, anterior segment with interpretation and report, unilateral  Coverage and payment for Category III codes remains at carrier discretion Decreases 48

Billing Specialized Services

Baseline or routine testing is Increases List in clinical records the order  Must base test order on medical necessity  Be aware of coding/testing requirements from payer  Bill with office service, if appropriate, and use modifier where indicated  Use interpretation and report where needed 49

Interpretation and Report

 Indications for performing the test  Test results with notation of reliability  Use of test results in treatment and management of the condition  Initiate treatment or plan to repeat testing or other care Decreases form 50

Modifiers

51

Selecting the Appropriate Modifier

        -24 Unrelated E/M Service, Same Physician, During Post-op period -25 Separate Service, Same Physician, Same Day -26 Professional Component Increases -51 Multiple Procedures -52 Reduced Service, Informational, Not Reduced Fee -54 Surgical Care Only -55 Post-Operative Care Only       -58 Staged Procedure Decreases -79 Unrelated Procedure, Same Physician, During Post-Op -TC-Technical Component -RT/LT Right, Left -E1 – E4 Puncta/Lid Identifiers 52

Modifier-25

Significant, separately Increases service Decreases “The patient’s medical record documentation is expected to clearly evidence that the evaluation and management service performed and billed was “above and beyond” the usual pre-operative and post-operative care associated with the procedure performed on that day” 53

Modifier-25

cont.

The need to perform an independent evaluation and management service may be prompted by a complaint, symptom, condition problem or circumstance which Increases service) provided.

As such, different diagnosis from those related to the procedure are not required for reporting of a significant, separately identifiable E/M service performed on the Decreases However, the record should document an important, notable, distinct correlation with signs and symptoms to make a diagnostic classification or demonstrate a distinct problem. 54

Healthcare Effectiveness Data and Information Set (HEDIS)

55

HEDIS

 Used by over 90% of the health care plans  73 provider services that managed care plans must provide for their covered lives  Many administrative services on required list  Two eye services included:  Yearly dilated eye examination for all diabetic patients Decreases  Glaucoma screening for high-risk patients  Currently dilated eye examination is the lowest percentage score of all services in HEDIS 56

What is Disease Management?

Disease Management is a system of Increases care interventions and communications for populations with conditions in which patient self-care efforts are significant Decreases  Supports the physician or practitioner/ patient relationship and plan of care,  Emphasizes prevention of exacerbations and complications utilizing evidence based practice guidelines and patient empowerment strategies, and  Evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health 57

Disease Management and Eye Care

 Integration of “all” health information via ICD-9 diagnosis codes  Until recently, data has been limited to medical and pharmacy data  Addition of dental data has yielded new standards for gingivitis/pregnancy  Eye care data is the next threshold and expected to yield valuable  Expect reporting incentives around DM area in the future 58

Diabetes Disease Management

Health plans and DM organizations are providing Increases that cost savings/avoidance has been validated Diabetic cost avoidance in a recent study shows direct and indirect diabetes cost avoidance of Decreases

*Disease Management: Volume 11, Number 3, June 2008

59

Increases

Documenting the Health Record

“Bullet Proof” Your Records

Decreases 60

Medical Record Guidelines

The medical record should be complete and legible The documentation of each patient encounter should include:  Reason for the encounter and relevant history physical examination  Findings and prior diagnostic test results  Assessment, clinical impression or diagnosis  Plan for care  Date and legible identity of the observer.

61

Medical Record Guidelines

cont.

     If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record Source: 1997 Documentation Guidelines 62

Resources

Tools for success: All of these are available in AOA Codes for Optometry    CPT 2009 ICD-9 2009 HCPCS Level II 2009 63

Questions?

64

THANK YOU!

65