The Problem The Current Solutions The Possible Solution The Challenge: Next Steps. The Problem. Medical Eye vs. Well

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1 Ask the AOA Coding Experts: Vision versus Medical? Doug Morrow, O.D. Harvey Richman, O.D. Rebecca Wartman, O.D. Medical Eye vs. Well Vision: The Great Coding Dilemma The Problem The Current Solutions The Possible Solution The Challenge: Next Steps Well vision visits vs. Medical visits Many approaches around the country Many with validity All have unacceptable aspects Key: Consistency in coding, regardless of payment method H2 AOA Third Party Center Coding Experts The Problem Rebecca H. Wartman, O.D Douglas C. Morrow, O.D Harvey B. Richman, O.D Medical Eye vs. Well Vision How to code How to differentiate How to be consistent How to play by the rules CPT code for Well Vision Unlikely Why the problem? Used to be carriers (MAC) have LCD for 92 code Can require use of 92 codes for medical claims Can require use of 99 codes for medical claims Private carriers inconsistent on code use May include refraction in 92 codes May include refraction in 99 codes May require S codes for well vision, sporadic No longer 99-medical and 92 well vision Medical Eye vs. Well Vision: The Great Coding Dilemma Fundamental difference: Medical care vs. well care Standard across the medical community Chief complaint and detail needed Medical decision-making -complexity Risk increased morbidity/mortality Examination more detailed Anterior segment Posterior segment Neurological Patient counseling Ordered tests Record review Assessment and Plan more involved H1 Coding approaches across nation Use medical diagnosis for all examinations Routine coverage - refractive diagnosis Concern: Diagnosis based on payment Creative diagnosing 1

2 Slide 6 H1 Not sure what this means here are you talking about Medical care below? Yes-that routine is not focused. Harvey, 5/17/2014 Slide 8 H2 Is this still true for MAC LCD? Have we reviewed all the carriers? If not we have to do this before we make this statement Still true for private carriers certainly For sure. Will do. Harvey, 5/17/2014

3 Coding approaches across nation Medical vs Wellness Medical vs Wellness 92004/14 medical No well vision under this code 99 medical 92002/12 well vision Concern: undercoding More than 7 elements performed Patient with Medical Plan and separate well vision plan Case History 68 yo established patient, not seen in 4 years Reports decreased vision LE VA OD 20/30 OS 20/70 Pupils equal, no APD EOM full, balanced Confrontation Fields Full to Finger Counting Patient with Medical Plan and separate well vision plan Many offices are faced with this dilemma More and more Medical Plans are adding wellness care Options: 1. Perform vision well exam and reschedule for medical 2. Inquire upon patient arrive which plan intend to use 3. Bill Medical Carrier and use well vision coverage for glasses 4. Bill Medical carrier and cross file to well vision plan for refraction and glasses Coding approaches across nation Medical vs Wellness Coding Systems Internally use S code for all well vision Internal code only Converted to plan accepted code All routine patients would create 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 Patient with Medical Plan and separate well vision plan SL : Normal but Lens nuclear sclerosis, cortical opacities OU IOP 18 OU Internal exam (volk super fundus & 20D) RPE changes + drusenou Optic nerve and peripheral fundus = normal Amsler grid normal OU Diagnoses: Cataract, combined OU ARMD, OU H5 The proper use of a coding systems is an important component for participation in any health care system. Coding approaches across nation Medical vs Wellness Principles of Medical Record Documentation System not working well Inconsistency between payors HIPAA violations: refractions/92000/99000 codes Many providers confused Need to extract phone price quoting issue Payer and provider abuse potential with S codes Patient with Medical Plan and separate 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 and exam 1. Medical record should be complete and legible 2. Documentation of each encounter should include: a) Reason for encounter b) relevant history c) physical examination findings d) prior diagnostic test results e) Assessment, clinical impression or diagnosis f) Plan of Care g) Date and legible identity of the observer (Even if you are the ONLY provider!!) 2

4 Slide 17 H5 If this is a quote- reference it in on the slide No Reference Harvey, 5/17/2014

5 Coding Basics- Don t Fall Asleep ICD-9-CM Diagnosis Codes ICD-10-CM Improvement Code to highest level of specificity Contains 3, 4, or 5 digits; be specific Find diagnosis in Alphabetical Index Verify diagnosis code in Numerical Index Codes expanded to maximum of 7 characters Added: Injury codes Codes extensions for external causes of injury Codes extensions for injuries Laterality Trimester information Alcohol and substance abuse Postoperative complications Coding Systems ICD-9-CM Codes (Routine?) ICD-10-CM Improvements CPT Procedure Codes What You Do ICD-9/10 Diagnosis Codes What You Find HCPCS Codes What You Supplied (sometimes what you did) Modifiers What s Different V41.0 Problems With Sight V41.1 Other Eye Problems V72.0 Examination of the Eyes and Vision 367.X Refractive Diagnosis Category Harmonized with other classifications DSM-IV - mental health disorders ICDO-2 cancer registries Nursing Removed relationships with procedures/procedure codes Revised diabetes codes to be consistent with ADA categories ICD-9-CM Diagnosis Codes ICD-10-CM ICD-10 Codes (Routine?) Identify diagnoses for medical records/reimbursement Owed by the World Health Organization (WHO) Changes effective October 1 every year Organized by: Index and Tables Index to diseases and injury Index to external causes of injury Table of Neoplasms Table of Drugs and Chemicals Alphabetical list of terms with codes Tabular list, a chronological list Divided into chapters based on body system or condition Z01.00 Encounter for examination of eyes and vision without abnormal findings Z01.01 Encounter for examination of eyes and vision with abnormal findings Z97.3 Presence of spectacles and contact lenses 3

6 Supply of Ophthalmic Materials H3 Medicare/Medicaid and Other Carriers HCPCS Codes V2020 V2799 HCPCS Codes Sxxxx Contact Lens and Spectacle Services, Ocular Prosthetics Procedure Codes For Eye Health- Well Vision Services Series General Ophthalmological Services Series Evaluation and Management (E&M) Services S-Codes 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 New Patient Defined New patient Established patient General Ophthalmologic Codes vs Evaluation and Management (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 Please note that some carriers state: Services that require minimal ophthalmologic examination techniques are reported with the E/M CPT codes (99201 through 99499) Evaluation and Management (E & M) 1995 or 1997 guidelines for E&M codes 1997 simpler, have to specify in audit This is 1997 guidelines from CPT codes Office Hospital Nursing facility Domiciliary/rest home Home Medicare no longer covers consultations 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 Difference between General Ophthalmologic and E&M Codes General ophthalmologic services Intermediate and comprehensive Do not require three key components o History o Examination o Medical decision-making Do not use documentation guidelines of CMS to determine proper code selection E & M Overview 1995 vs

7 Slide 28 H3 There are private carriers who use the HCPCS codes as well so this is misleading I think Got it Harvey, 5/17/2014

8 Elements of E & M Codes Elements of E & M Codes Review of Systems Major elements Chief Complaint Always History Examination Medical decision-making An inventory of body systems obtained via questions to identify signs/symptoms that patient may be experiencing or has experienced Constitutional Eyes Musculoskeletal Other factors considered Counseling Coordination of care Nature of presenting problem Time History of present illness 8 elements 2 levels Review of systems 14 elements 3 levels Past, family, social history 3 elements 2 levels Ears, nose, throat (E/N/T) Cardiovascular Respiratory Gastrointestinal Genitourinary Integumentary Neurological Psychiatric Endocrine Hematologic/Lymp hatic Allergic/Immunolo gic Elements of E & M Codes History of Present Illness Review of Systems 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 Chronological description of development of present illness from: First sign and/or symptom Previous encounter to present Problem oriented: +/- system related to problem Extended problem oriented: +/- 2-9 systems Complete: +/- 10 or more systems Elements of E & M Codes History of Present Illness Review of Systems Chief Complaint Examples CC: Osteoarthritis CC: Sore throat CC: Dizziness CC: Red eye-right CC: Greenish discharge-right eye CC: Scratchy left eye Elements Location Quality Severity Duration Timing Context Modifying factors Associated sign & symptoms Levels Brief: 1-3 elements Extended: 4+ elements 1997 documentation guidelines Descriptions of the elements (e.g., location, quality, severity, etc.) or status of three chronic/inactive diseases. 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 5

9 Past, Family, Social History Overall History Components Examination Elements Problem focused Past history Family history HPI: Brief (1-3 elements) ROS: Not applicable PFS: Not applicable 4 Levels (1997) Problem focused Expanded problem focused Social history Expanded problem focused HPI: ROS: PFS: Brief (1-3 elements) Problem oriented (1 specific system) Not applicable Detailed Comprehensive Past, Family, Social History Overall History Components Examination Elements Pertinent: One in any of the three areas Detailed HPI: Extended(4+ elements) ROS: Extended (2-9 elements) Single System 14 elements Visual Acuity SLE cornea/tears Complete: One in all three areas for new Two of three for established PFS: Pertinent(1/3 elements) Comprehensive HPI: Extended (4+ elements) ROS: Complete (10 elements) PFS: Comprehensive (3/3 NP or 2/3 EP) Confrontation Field EOM/Alignment Conjunctiva Adnexa/lacrimal Pupils/iris IOP SLE anterior chamber SLE - Lens DFE Optic nerve DFE Posterior seg Orientation Mood/affect Overall History Components HPI Summary Table Examination Elements Single System Problem focused Expanded problem focused Detailed Comprehensive Test visual acuity (Does not include refraction) Gross visual field testing by confrontation Test 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 6

10 Image courtesy Topcon 5/19/2014 Examination Elements Single System Slit lamp examination Corneas Anterior chambers Crystalline lens Measurement of intraocular pressures Number of possible diagnoses Amount- complexity of medical records, diagnostic tests, and/or other information Risk of significant complications, morbidity and/or mortality Comorbidities Multiple diagnoses Moderate management options Moderate risk Extensive number diagnoses Extensive management options High risk Examination Elements Single System Dilated fundus examination Ophthalmoscopicexamination Optic discs Posterior segments PLUS - Orientation to time place person AND - Mood and affect (eg, depression, anxiety, agitation) Indirect ophthalmoscope Other factors to secondarily consider Counseling Coordination of care Nature of presenting problem Time Time is key when counseling and care coordination are the primary component (more than 50%) Straightforward/Minimal One - Presenting problem(s) Simple - Diagnostic procedures Simple - Management options Examination Elements Single System Problem oriented 1-5 elements Low Expanded problem oriented 6 elements Detailed 9 elements Comprehensive 14 elements* * all elements plus one Mood or orientation Minimum number diagnoses Minimal management options Minimal risk Limited number of diagnoses Limited management options Low risk 2+ Presenting problem(s) More complicated diagnostic procedures Management options 7

11 Moderate 1+ chronic Presenting problem(s) More complicated - Diagnostic procedures Management options Document Findings Visualizations Plans Test results Consultations Old record requests In short EVERYTHING CPT Examples for Eye Care New Patients 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) Initial office visit for a 55-year-old female with chronic blepharitis. There is a history of use of many medications Initial office visit for a 70-year-old diabetic patient with progressive visual field loss, advanced optic disc cupping and neovascularization of retina. High Presenting problem(s) Extremely complicated - Diagnostic procedures Management options Elements of Codes Code History Exam Decision Problem Focused Problem Focused Straightforward NA NA NA Staff only No Doctor Abuse potential Per CMS Expand Problem Expand Problem Straightforward Focused Focused Problem Focused Problem Focused Straightforward Detailed Detailed Low CPT Examples for Eye Care Est Patients Office visit for a 65-year-old female, established patient, with primary glaucoma for interval determination of intraocular pressure and possible adjustment of medication 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 Expand Problem Focused Expand Problem Focused Low The highest level of risk in any of the three determines overall risk Presenting problems(s) Diagnostic procedures Management options Elements of Codes Code History Exam Decision Comp Comp Moderate Detailed Detailed Moderate Comp Comp High Comp Comp High General Ophthalmologic Services C O D E S

12 CPT Codes Note: Current Procedural Terminology( American Medical Association) is the only accepted source of definitions for these services Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient ;comprehensive, new patient, 1 or more visits Comprehensive Ophthalmological Services & Introduction in CPT General evaluation of the complete visual system (1 or more sessions) Includes: History General medical observation External examination Ophthalmoscopicexamination Gross visual fields Basic sensorimotor examination Often includes: Biomicroscopy Examination with cycloplegia or mydriasis Tonometry. Always includes: Initiation/continuation of diagnostic and treatment programs Diagnostic and Treatment Program Includes, but not complete list: Prescription of medication Special ophthalmological diagnostic or treatment services Consultations Laboratory procedures Radiological services CPT Codes Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient ;comprehensive, established patient, 1 or more visits 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. 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 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. Intermediate Ophthalmological Services and 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 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 Intermediate COMPREHENSIVE 9

13 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 examination can also includes: None of the following special tests have individual CPT codes so are included in intermediate and/or comprehensive general ophthalmologic examinations Laser interferometry Potential acuity meter Keratometry Exophthalmometry Transillumination Corneal sensation Tear film adequacy Phacometry Schirmer s test Slit lamp History General medical observation 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 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 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. Coding Guidelines Chief Complaint- Reason for visit Still necessary Documentation To establish medical necessity General medical observations Require dilation for 92004/ (? per CPT) Must include initiation/continuation of diagnostic and treatment programs Intermediate Examination Seven or fewer elements AND Examples of Intermediate Examination From CPT Acute complicated condition (eg, iritis) not requiring comprehensive ophthalmological service Review of history External examination Ophthalmoscopy Biomicroscopy 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 and treatment program seems to be the most audited item by Medicare 10

14 92000 Codes Special Ophthalmological Services Describe services in which a special evaluation of part of the visual system is made, which goes beyond the services, or in which special treatment is given. Special ophthalmological services may be reported in addition to the general ophthalmological services or evaluation and management services. Effect of Lenses With Lenses How about something routine? Without Lenses Series Codes Refraction S-Codes Extended Ophthalmoscopy* Not a Routine BIO Angiography (Fluorescein / Indocyanine Green) Fundus Photography* Scanning Laser Technology* Color Vision Examination Gonioscopy External Ocular Photography* Sensorimotor Evaluation Visual Fields* Determination of refractive state Statutorily not covered by Medicare RVU $20.42 Consider Modifiers S0620 routine ophthalmologic examination including refraction, new patient S routine ophthalmologic examination including refraction, established patient Routine Examination Codes? Special Ophthalmological Services to 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 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 Annual dilated exam for diabetics Special code for glaucoma screening G0117 with V80.1 S CODES PROBLEMS No valuation No further definitions Insurers free to interpret at will 11

15 Preventative Medicine Codes CPT - Preventative Medicine Services Used to report the preventative medicine evaluation and management of infants, children, adolescents, and adults Include the management of insignificant or trivial problems which do not require additional work Comparison of RBRVS Established Patient H6 Preventative Medicine to Range: 2.87 to 3.81 Average: 3.38 General Ophthalmologic (Inter) (Comp) 3.52 Fundamental difference: medical vs. well vision care Chief complaint and detail needed Medical decision-making complex Risk increased morbidity/mortality Examination more detailed Anterior segment Posterior segment Neurological Patient counseling Ordered tests Record review Preventative Medicine Codes Possible Solution Take home message New Patient < 1 year old years years years years years >65 years Established Patient < 1 year years years years years years >65 years No single, simple answer Current system confusing at best No forthcoming well vision code from CPT Fear 92 codes will be deleted if approach CPT Can use existing CPT category 1 codes REMEMBER: Consistency in coding REGARDLESS of payment source No single, simple answer Confusing system at best No forthcoming well vision procedural code Fear 92 codes will be deleted Can use existing category 1 codes REMEMBER: Be consistent when coding across the board, REGARDLESS of payment method Comparison of RBRVS New Patient Preventative Medicine H to Range: 3.10 to 4.64 Average: 3.97 General Ophthalmologic (Inter) (Comp) 4.22 Possible Future Preventative Medicine codes ( ) Precedent-some carriers require for child (Superior Vision) Currently little general use of this approach Encourage HIPAA compliance by payers refraction not a part of any other code Encourage HCPCS to delete S codes maybeafter progress with Preventative Medicine codes 12

16 Slide 102 H7 Are these new RBRVUs? Fixed Harvey, 5/17/2014 Slide 103 H6 Are these values current? Fixed Harvey, 5/17/2014