Ask the AOA Coding Experts: Top Ten Questions. Doug Morrow, O.D. Harvey Richman, O.D. Rebecca Wartman, O.D.

Transcription

1 Ask the AOA Coding Experts: Top Ten Questions Doug Morrow, O.D. Harvey Richman, O.D. Rebecca Wartman, O.D.

2 Disclaimers for Presentation 1.All information was current at time it was prepared 2.Drawn from national policies, with links included in the presentation for your use 3.Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations 4.Prepared and presented carefully to ensure the information is accurate, current and relevant 5.No conflicts of interest exist for the presenterfinancial or otherwise

3 Disclaimers for Presentation 6. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services 7. AOA, AOA-TPC, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein

4 AOA Third Party Center Coding Experts Rebecca Wartman OD Douglas Morrow OD Harvey Richman OD

5 Coding Basics- Don t Fall Asleep

6 Coding Systems CPT Procedure Codes What You Do ICD-9-CM/ICD-10-CM Diagnosis Codes What You Find HCPCS Codes What You Supplied or Do Modifiers What s Different

7 CPT Procedure Codes Identifies physician services and procedures Copyright held by the American Medical Association Updated yearly through CPT Editorial Process Changes effective January 1 every year

8 Question 1A Interpretation of Testing I just bought an OCT. The company installed and taught us how to use it but they didn t teach us how to interpret it. Can you teach us?

9 Question 1A Interpretation of Testing NO! We cannot teach you how to interpret your OCT findings BUT We can give you coding guidelines for OCT use AND Resources to learn how to interpret findings: Lectures Websites Manufacturer materials Experience

10 Question 1 Dilation I was told by one of my friends that I should only use intermediate level codes for routine eye exams but I dilate all my patients. Doesn t that make them comprehensive exams?

11 Not necessarily! Question 1 Dilation General Ophthalmic Services Codes New Patient vs. Established Comprehensive vs. Intermediate Elements of services Guidance on coding

12 General Ophthalmologic Services 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

13 General Ophthalmologic 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

14 General Ophthalmologic Services Comprehensive Ophthalmological Services & Introduction in CPT General evaluation of the complete visual system (1 or more sessions) Includes: History General medical observation External examination Ophthalmoscopic examination Gross visual fields Basic sensorimotor examination Often includes: Biomicroscopy Examination with cycloplegia or mydriasis Tonometry. Always includes: Initiation/continuation of diagnostic and treatment programs

15 General Ophthalmologic Services 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

16 General Ophthalmologic Services Diagnostic and Treatment Program Includes, but not complete list: Prescription of medication Special ophthalmological diagnostic or treatment services Consultations Laboratory procedures Radiological services

17 General Ophthalmologic Services How Differ from E&M Intermediate & Comprehensive Ophthalmological Services: Medical decision making cannot be separated from examining techniques Itemization of service components is not applicable Slit lamp examination Keratometry Routine ophthalmoscopy Retinoscopy Tonometry Motor evaluation

18 General Ophthalmologic Services Some Medicare Carriers further define what constitutes Intermediate and Comprehensive Ophthalmic Examinations Intermediate Source appears to be CPT Assistant Article August 1998 and the CPT introduction and definitions This review helps in determining intermediate vs comprehensive service levels COMPREHENSIVE

19 General Ophthalmologic Services Ten Elements of Ophthalmologic Examination Confrontation fields Eyelids/adnexa Ocular motility Pupils/iris Cornea Anterior Chamber Lens Intraocular pressure Retina (vitreous, macula, periphery, and vessels) Optic disc (Should be 12 elements including acuity and bulbar and palpebral conjunctiva but not always listed)

20 General Ophthalmologic Services Comprehensive examination eight or more elements including: Fundus examination with dilation** Motor evaluation **Note that CPT definitions do NOT require dilation but some carriers dosome with further statement with dilation unless contraindicated

21 General Ophthalmologic Services Intermediate Examination Seven or fewer elements AND Additional Ophthalmic Tests

22 Question 2 Refraction Since insurance is not covering, my patients are getting mad about my refraction and contact lens exam fees. Is there a way that I can incorporate them into my eye exam fee?

23 Question 2 Refraction Refraction and HIPAA Contact Lens Codes Inducement Violations S-Codes Presentation of fees to patient

24 General Ophthalmologic Services 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

25 Refraction Determination of refractive state Statutorily not covered by Medicare RVU $20.42 Consider Modifiers

26 General Ophthalmologic Services Coding Guidelines Refraction not covered by Medicare May file for denial GY modifier may be necessary indicates that the service is statutorily excluded from Medicare coverage Advanced Beneficiary Notice (ABN)

27 S-Codes S0620 routine ophthalmologic examination including refraction, new patient S routine ophthalmologic examination including refraction, established patient

28 Routine Examination Codes? S CODES PROBLEMS No valuation No further definitions Insurers free to interpret at will

29 Fee Presentation Just because the patient has insurance doesn t mean that the procedure is covered Know the plans and how to present to patient Plan rules not always HIPAA Compliant

30 Question 3 Cataract Post op I keep getting denials from Medicare for submission of a second eye cataract post op. What am I doing wrong?

31 Question 3 Cataract Post Op Modifier Use Surgical Correct Billing Guidelines

32 Post Op Surgeon -54 modifier indicating surgical care only Post-op period = 90 days Surgery day = Day 0 Transfer of care Transfer date Surgical Procedure Surgical Diagnosis

33 Post Op-Modifiers -55 modifier -79 modifier RT modifier LT modifier

34 Key Points Summary Thorough documentation is vital Communication with the surgeon is critical Surgeon must document the exchange of care Patient must understand exchange of care process Patients must have choice for post-operative care Communication with the patient is critical ALWAYS act in the best interest of the patient

35 Question 3A Cataract Post Op How do you handle a patient that is covered by a commercial carrier, is under 65 and has cataract surgery and the insurance company tells you they will not pay for co-management? Do I bill E&M s for the post op? Do I fight with the carrier? Or both?

36 Question 3A Cataract Post Op Insurance company policies Options?

37 Question 4 Fundus Photography My camera company told me that since my camera does a better job of looking for retinopathy then I do, that I can I use that instead of dilating my diabetic patients and bill It makes sense.

38 Question 4 Fundus Photography Fundus Photography Diabetic Eye Exam Requirements PQRS requirements

39 Diabetes and Retinal Examinations American Diabetes Association and the National Institutes of Health s positions retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the onset of diabetes Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination soon after diagnosis. Subsequent examinations for type 1 and type 2 diabetic patients are generally repeated annually

40 Diabetes and Retinal Examinations American Diabetes Association and the National Institutes of Health s position Photos are not a substitute for a comprehensive eye exam

41 92250 Purpose CPT considered medically necessary to monitor pathology Reimbursed by Medicare and other third party payers per guidelines for fundus photography

42 Question 5 PQRS If my patient is not taking any medicine, how do I document PQRS for them?

43 Question 5 PQRS PQRS before 2014 Eye Codes ERx and EHR PQRS in 2014 and beyond 9 measures Public health options

44 Physician Quality Reporting System PQRS 2014 If you DO NOT report in 2014 you will be penalized in 2016 Your Medicare reimbursement will drop by 2.0% 2017 penalties will be based on 2015 reporting performance

45 Avoiding 2015 Penalty- May still be possible If you DID NOT report AT LEAST ONE PQRS measure in 2013, your Medicare reimbursement will drop by 1.5% for 2015 May still be time ONLY IF you have not yet filed all 2013 claims (cannot re-file previously submitted claims to add PQRS measures) File ONE 2013 CLAIM with PQRS measure to avoid 2015 penalty- before Feb 28, 2014

46 Satisfactory PQRS Reporting Claims-Based for 2014 PQRS Bonus For satisfactory reporting: Must report at least 9 measures from 3 different National Quality Strategy NQS) domains, 50% of time for each measure This does NOT mean 9 measures on every claim at least 50% of time Choose 9-10 measures from 3 different domains and use them when appropriate at least 50% of the time

47 #130 Documentation of Current Medications in the Medical Record G8427: List of current medications documented by the provider, including drug name, dosage, frequency and route OR G8430: Provider documentation that patient is not eligible for medication assessment OR G8428: Current medications (includes prescription, over-thecounter, herbals, vitamin/mineral/dietary [nutritional] supplements) with drug name, dosage, frequency and route not documented by the provider, reason not specified

48 What if they are hypertensive? HTN exclusions as the following: Not Eligible A patient is not eligible if one or more of the following reason(s) are documented: Patient has an active diagnosis of hypertension Patient refuses to participate (either BP measurement or follow-up) Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated G8784: Blood pressure reading not documented, documentation the patient is not eligible G8951: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible

49 Question 5A Meaningful Use I want to meet Meaningful Use 2, but it is too hard for my staff to enter into the computer. Can I just check off the boxes because I write it all down correctly on the record?

50 Question 5A Meaningful Use Meaningful Use 2 guidance AOA resources Meaningful Use audits across the country

51 Question 6 Foreign Body If a patient comes in with a complaint of something flying in his eye and I find a foreign body, how do I bill it? I heard someone once say you can t bill an office visit, is that true?

52 Question 6 Foreign Body Modifiers Surgical Correct Billing Guidelines New Patient vs Established Patient ICD-10-CM rules

53 Foreign Body Removal Conjunctival FB Removal, superficial Conjunctival FB Removal, embedded Corneal FB Removal w/o Slit Lamp Corneal FB Removal w/ Slit Lamp

54 Foreign Body Removal ICD-9 diagnosis codes Conjunctival Foreign Body Corneal Foreign Body Procedure billed stand alone Procedure billed with E&M code

55 Multiple Foreign Body Removal Same code for one or multiple foreign bodies -51 modifier (multiple procedures) -50 modifier (bilateral procedures)

56 Other Corneal Procedures Scraping of cornea, diagnostic Removal of corneal epithelium

57 Supporting ICD-9 Codes Scrape and Culture Cornea Corneal Ulcer Debridement of Cornea Recurrent Erosion Herpes Simplex Keratitis Corneal Dystrophy, unspecified

58 Billing Surgical Codes Surgical codes are stand alone codes Not usually billed with E&M codes -25 modifier if E&M visit results in decision for surgical procedure

59 Question 7 Multiple Procedures My glaucoma patient can only come in once per year because their daughter visits only in the summer. I need to do ophthalmoscopy, fundus photos, gonioscopy, pachymetry, fields and OCT on that day or else she will never get it done. I was told that we can do that. What should I do?

60 Question 7 Multiple Procedures Multiple Procedure Payment Reduction Modifiers Medical Necessity Local Coverage Determination (LCD) for Services That Are and Are Not Reasonable and Necessary Patient education

61 Multiple Procedure Payment Reduction Modifications 20% reduction to practice expense component for 2+ service(s) furnished by a physician or group practice in an office setting on same day

62 Multiple Procedure Payment Reduction Modifications April 1, 2013, American Taxpayer Relief Act of 2012 applied up to 50% multiple procedure payment reduction modifications (MPPR) 20% reduction to technical component for 2+ diagnostic ophthalmology services furnished to same patient-same physician-same day 50% reduction for 2+ surgical procedures furnished to same patient-same physiciansame day

63 Multiple Procedures on Same Day A and B Scans Pachymetry Corneal Topography Sensorimotor exam Visual Field exams Scanning Laser Remote imagining-retinal FA Fundus photos Oculoelectromyography Color vision Dark adaptation External photos Spectular Microscopy

64 Question 8 Keratoconus Contact Lenses I finally had a patient with keratoconus that the insurance company paid for the visit with the new code. The problem was that the carrier did not pay for the contact and said it is not the patient s responsibility. What can I do?

65 Question 8 Keratoconus Contact Lenses HCPCS code options Private coverage options Medicare options-dmerc

66 92072 CPT Fitting of a contact lens for management of keratoconus, initial fitting. For subsequent fittings, please use either the 9921X or 9201X codes. Report materials in addition to this code, using either or the appropriate HCPCS Level II material code.

67 92072 The follow up for the contact lens fitting would be billed with E&M codes. Once the initial contact lens fitting is complete, cannot be used again after this initial fitting. If the keratoconus patient needed to be treated (fit) again the fitting would not be used, but instead use an E&M code and for the fitting.

68 92071 CPT Fitting of a contact lens for treatment of ocular surface disease Report materials in addition to this code, using either or the appropriate HCPCS Level II material code. This is the appropriate code to use for fitting a bandage contact lens.

69 92071 The code would be used when a patient has a traumatic injury (abrasion) or another corneal disorder such as a recurrent corneal erosion, filamentary keratitis or bullous keratopathy. The patient or payer would be billed for the appropriate office visit code, either a or code and the code for the treatment with the bandage contact lens.

70 92071 The provider may also use a bandage contact lens after the removal of a corneal foreign body (65222). In this case the code can be billed as a bandage, but some payers will deny the because the is valued with a wound dressing included in the payment for the foreign body removal.

71 Question 9 ICD-10-CM Revisited I keep seeing these webinars and articles about ICD-10-CM. If I only see regular patients, do I need to worry about this?

72 Question 9 ICD-10-CM Revisited Federal Law AOA Eye-learn Vision Plans and coding EHR Vendors CMS website CDC ICD-10-CM website

73 Why change ICD-9-CM ICD-9-CM is 30 years old ICD-10-CM? Produces limited data about medical conditions Uses outdated terms Is inconsistent with current medical practice Structure limits number of new codes Many ICD-9 categories are full ICD-10-CM everywhere since 1994 (except the US and Italy) Published by World Health Organization (WHO) US Version maintained by Centers for Disease Control (CDC)

74 ICD-10-CM Improvements Harmonizes with other classifications Removes relationships with procedure codes Revises diabetes codes - consistent with ADA Information on diseases and conditions and causes grouped as follows: Communicable diseases General diseases that affect the whole body Local diseases arranged by site Developmental diseases Injuries External causes

75 ICD-10-CM Resources American Optometric Association CDC ICD-10-CM Official USA site release of ICD-10-CM at bottom of page has all the downloads ICD-10-CM Guidelines [PDF KB] ICD-10-CM PDF Format ICD-10-CM List of codes and Descriptions (updated 7/3/2013) CMS ICD-10-CM information X World Health X but Use for general training only

76 Question 10 Non Covered Procedures My doctor went to a lecture recently and told us we can be charging patients for photography of the cornea for our dry eye patients. When we do, the insurance company keeps denying. Can you help?

77 Question 10 Non Covered Procedures Anterior Segment imaging spectral microscopy External Ocular Photography Medical Necessity LCD vs. CPB Glaucoma Suspect Macular Drusen

78 Medical Necessity A service that appears to meet the technical requirements for coverage may be excluded if that service: not generally accepted as safe and effective not supported in peer-reviewed medical literature not medically necessary in a specific case, or for a specific medical diagnosis furnished at a level, duration, dosage or frequency not appropriate for a specific patient or clinical condition

79 Medical Necessity not furnished in manner consistent with standards of care not furnished in appropriate medical setting (place of service) furnished in manner primarily for patient/provider convenience device not approved by FDA or not included in an FDA trial test or service considered obsolete by the medical community, and replaced by more efficacious services

80 Just because you get paid Resources doesn t make it right Medicare Carrier CMS CCI edits Private carrier guidance Ask the Coding Experts AOA Coding Today State Association Third Party Center

81 Finally Any last questions? All you coding issues are solved! Right! RIGHT?????

82 THANK YOU