J. Rumpakis, O.D., M.B.A. Practice Resource Management, Inc

Transcription

1 1 1 Cracking The Code Clinical Case Management In The ICD-10 Era Contact Lenses John Rumpakis, OD, MBA John Rumpakis, OD, MBA 2 Named the Chief Medical Coding Editor for Review of Optometry & Optometric Management, he has been extensively published on the topics of third party coding & Dr. Rumpakis is currently President & CEO of Practice Resource Management, Inc., a firm that specializes in providing a full array of consulting, appraisal, and management services for healthcare professionals and industry partners. He has developed some of the leading Internet-based software applications for the medical/eye care field such as CodeSAFEPLUS.com ( the industry leading cloud-based CPT & ICD Code Data and Information Service, and offers personal medical coding consultation through JustAskJohn ( He is also the founder of Opt-ED Professional Continuing Education ( which creates and delivers top tier continuing education around the country as well as Opt-IN which provides optometric marketing and promotional services. billing, strategy development and execution, practice management, team building, maximizing effectiveness and profitability, including the textbook Business Aspects of Optometry. Dr. Rumpakis is a popular lecturer both nationally and internationally. In addition to having had a successful solo practice, Dr. Rumpakis developed the practice management curriculum at Pacific University College of Optometry and taught optometric & medical economics there for over a decade. A 1984 graduate of Pacific University College of Optometry, he served as a volunteer for the AOA for near 17 years and sits on numerous advisory boards, and board of directors for companies both in and out of the ophthalmic industry. 3 Financial Disclosures John Rumpakis, OD, MBA I Am A Project Based Consultant & Have Received Honoraria From: (Partial Listing) Alcon Laboratories Allergan Eye-Tel Imaging RevolutionEHR Carl Zeiss Meditec Beaver-Visitec Bausch & Lomb VisionWeb Optos OfficeMate Essilor of America Opticare Vistakon Maximeyes Wal-Mart United Health Care CooperVision Maculogix Luxottica Macuscope Vision Source EMRLogic MacuRisk Topcon Bio-Tissue ArcticDX Kowa Optimed CyclopsEMR TearLab Modernizing Medicine HeartSmart ECRVault Paragon Annidis Freedom-Meditech Diopsys Nicox Chief Medical Clinical Coding Editor Review Of Optometry & Optometric Management JustAskJohn Personalized Medical Coding Consultation ( CodeSAFEPLUS ( Founder Opt ED, Professional Optometric Continuing Education Founder Opt IN, Optometric Marketing & Promotions WhatsMyPracticeWorth.com Online Practice Appraisals

2 2 Disclosures All fees represented within this presentation are the 2015 Medicare National Average Maximum Allowable Reimbursements for each procedure listed as of January 29th, All information regarding policies, procedures, guidelines and definitions is current as of January 29th, Each viewer is responsible to be current in their own geographical jurisdiction interpretation of policies, procedures, guidelines and definitions prior to implementation within their own practice. The coding examples contained this presentation are examples only and each practitioner should apply these coding guidelines to what is actually recorded in the patients medical record before submitting any claim to a third party carrier. 4 Course Description & Objectives Course Description Using case examples, lecturer will present common and not so common specialty contact lens cases seen within optometric practice and ways we can improve our clinical skills from the case history, examination to medical decision making. Additionally, this course will discuss how contact lens related clinical care will be impacted by ICD-10. Course Objectives Review the importance of the case history in clinical decision making Gain a better understanding of ICD-10 and how to prepare your practice Review differences between ICD-9 and ICD-10 and how it affects each case presented Better differentiate the common and not so common contact lens related cases Utilize advanced technology in clinical care Discuss evidence based treatment and management of various contact lens issues 5 Learning Objectives Understanding That Your Medical Record Is Nothing More Than An EXTENSION OF YOUR CLINICAL CARE Definitions Medical Necessity & The Chief Complaint ICD Changes: The Move From ICD-9 to ICD-10 The Ophthalmic Coding Guidelines 920XX codes Compliance Issues And The Medical Record Demystifying E/M Coding Guidelines 992XX codes 1997 E/M Guidelines How To Translate The Exam Performed Into Coding Language Contact Lens Codes Definitions & Application 6

3 Coding Requires 2015 Rules Get Your Resource Material By Book CPT 2015 ICD HCPCS Level II 2015 Or Get Everything Updated AUTOMATICALLY Online Cloud-Based Resources & Questions About The Lecture? Me 10 If I Don t Understand IT & Practice IT IT May Be Taken Away So I know how to do it, but How Do I Maximize The Return On My Intellectual Property?

4 4 12 Your Practice Is Like A Bucket Refractive & Contact Lens Revenue Medical Eye Care Revenue Contact Lens Drop Outs Patients Going Elsewhere For Medical Eye Care Avoiding The Race To Zero 13 Reimbursement (Income) Patient Volume (Exams per hour) Practice Profit 17 The trend is clear that we are shifting to a benefit structure that is borne by the recipient of the care, rather than a third party provider.

5 5 But John, I m So Confused Everybody s An Expert??? There are so many different people that say so many different things 21 TRANSPARENCY Important Definitions 22 Fraud When someone intentionally falsifies information or deceives Medicare. The Only Difference Between Fraud & Abuse Is Intention. Abuse When health care providers or suppliers don t follow good medical practices, resulting un unnecessary costs, improper payments, or services that aren t medically necessary. Education/Training/CMSNationalTrainingProgram/Downloads/2013-Fraud-and-Abuse- Prevention-Workbook.pdf

6 6 23 CMS Fraud Detection - Past & Present Past Providers suspected of fraudulent activity were put on prepay review, sometimes indefinitely CMS initiated overpayment recovery Law enforcement determined if an arrest is appropriate Present Denies individual claims Its contractors use prepay review as an investigative technique Revokes providers for improper practices Collaborates with law enforcement before, during and after case development Addresses the root cause of identified vulnerabilities Education/Training/CMSNationalTrainingProgram/Downloads/2013-Fraud-and-Abuse- Prevention-Workbook.pdf The Government Recovery Is Hitting Records! 25 26

7 7 Obama Administration Announces Ground-Breaking Public-Private Partnership to Prevent Health Care Fraud July 26, 2012 For Immediate Release HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced the launch of a groundbreaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers. The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry antifraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders. It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions. One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect health care fraud schemes. Former Optometrist Sentenced in Medicaid Fraud Case FOR IMMEDIATE RELEASE : Wednesday, December 5, 2012 CONTACT: Seventh Sara Circuit Rabern Court (605) Judge Janine M. Kern ordered him to pay a total of $363, in restitution to Medicaid and Medicare. Feldman allowed PIERRE, the S.D.- South Attorney Dakota General Board Marty of Optometry Jackley announced to revoke today that his license Cary Stephen in October. Feldman, 60, Spearfish, was sentenced to serve 15 years in prison for committing Medicaid fraud. Seventh Feldman Circuit entered Court Judge a plea Janine of M. guilty Kern suspended on October the execution 11, 2012, of sentence to grand on theft several by conditions. deception, Judge a Kern class ordered 4 felony, Feldman and to serve making 180 days false in jail claims, and ordered a class him 5 to felony, pay a total of $363, pursuant in restitution to a plea to Medicaid agreement and Medicare. reached Feldman with the turned State. over Feldman a coin collection admitted with an estimated value of $157,000, and paid an additional $80,000 to the government, so his remaining restitution that he balance knowingly is $126, and intentionally Feldman was also submitted ordered to false serve claims 300 hours to of the community South service, Dakota pay costs Medicaid of $ program to the State and and to court Medicare. costs of $208. Feldman began allowed submitting the South Dakota the false Board claims of Optometry in late to revoke 2008, his and license continued October. until early Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a class 4 felony, and The making case false was claims, investigated a class 5 felony, and pursuant prosecuted to a plea by agreement the South reached Dakota with the State. Feldman Medicaid admitted Fraud that Control he knowingly Unit, and with intentionally assistance submitted from false the claims South to Dakota the South Dakota Medicaid Department program of and Social to Medicare. Services, Feldman the admitted federal that Department he submitted of claims Health to Medicaid and and to Medicare for consultation services, even though he had not provided such services. Feldman began Human submitting Services the false Office claims of in Inspector late 2008, and General, continued the until South early Dakota Division of Criminal Investigation, the Spearfish Police Department, the Rapid City The Police case was Department, investigated and the prosecuted Pennington by the County South Dakota Sheriff s Medicaid Office, Fraud the Control Unit, with assistance from the South Dakota Department of Social Services, the federal Department of Health Pennington County Office of State s Attorney, the Minnehaha County and Human Services Office of Inspector General, the South Dakota Division of Criminal Investigation, the Sheriff s Spearfish Office, Police Department, and the the South Rapid Dakota City Police Office Department, of United the Pennington States Attorney. County Sheriff s Office, the Pennington County Office of State s Attorney, the Minnehaha County Sheriff s Office, and the South Dakota Office of United States Attorney. 29 June 6, 2013 Press Release Medicare Urges Seniors To Join The Fight Against Fraud In mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states. Update on CMS Anti-Fraud Efforts The Affordable Care Act has enabled CMS to expand efforts to prevent and fight fraud, waste and abuse. Over the last four years, the Obama administration has recovered over $14.9 billion in healthcare fraud judgments, settlements, and administrative impositions, including record recoveries in 2011 and Since the Affordable Care Act, CMS has revoked 14,663 providers and suppliers ability to bill in the Medicare program since March These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules. In 18 states, the number of revocations has quadrupled since CMS put the Affordable Care Act screening and review requirements in place, as well as the implementation of proactive data analysis to identify potential license discrepancies of enrolled individuals and entities. These efforts are ensuring that only qualified and legitimate providers and suppliers can provide health care products and services to Medicare beneficiaries.

8 8 30 Ripped From The Headlines CMS Proposes New Safeguards and Incentives to Reduce Medicare Fraud On April 24, 2015 CMS issued a proposed rule that would increase rewards paid to Medicare beneficiaries and others whose tips about suspected fraud lead to the successful recovery of funds to as high as $9.9 million. In On April 24, addition, 2015 CMS a new issued funding a opportunity proposed released rule that this month supports the would increase expansion rewards of Senior paid Medicare to Medicare Patrol activities beneficiaries to educate Medicare beneficiaries on how to prevent, detect, and report Medicare fraud, waste, and others whose and abuse. tips The about proposed suspected rule would also fraud strengthen lead to certain provider enrollment provisions including allowing CMS to deny enrollment of the successful providers recovery who are of affiliated funds to with as an high entity as that $9.9 has unpaid Medicare debt, million. In addition, deny, or revoke a new billing funding privileges opportunity for individuals released with felony convictions, and revoke privileges for providers and suppliers who are abusing their billing this month supports privileges. the expansion of Senior Medicare Patrol activities These to proposed educate changes Medicare will support beneficiaries the administration s comprehensive approach to program integrity, including the work being done with the how to prevent, Health detect, Care Fraud and Prevention report and Medicare Enforcement fraud, Action Team, a joint effort between HHS and the Department of Justice to fight health care waste, and fraud. abuse. This joint effort recovered a record $4.2 billion in taxpayer dollars in fiscal year The proposed rule would also strengthen certain provider enrollment provisions including allowing CMS to deny enrollment of providers who are affiliated with an entity that has unpaid Medicare debt, deny, or revoke billing privileges for individuals with felony convictions, and revoke privileges for providers and suppliers who are abusing their billing privileges. And It s Not Just CMS We Need To Worry About! What Is A Red Flag That Triggers An Audit? Using codes under review by the OIG Not reviewing your submitted claims against recovery audit issues Abusing codes Aberrant or inconsistent billing patterns Maximizing revenue without sufficient documentation Cloning of documentation Not understanding definitions of modifiers and inappropriate use of modifiers 32

9 9 33 What Else Should I Worry About? New Rules Implemented In 2013 & Continued Into 2015: Multiple Procedure Payment Reduction Place of Service Codes Legibility of Medical Records New Claim Submission Guidelines Special Ophthalmic Procedures Self Referral Coding The Sequester OIG 2015 Work Plan OIG Strategic Plan, New Codes In Interprofessional telephone/internet assessment and management service provided by a consultative physician including and written report to the patient s treating/requesting physician or other qualified health care professional; five to 10 minutes of medical consultative discussion and review same as above with minutes of consultation same as above with minutes of consultation same as above with above 31 minutes of consultation 0329T Monitoring of IOP for 24 hours or longer, Uni/Bi, With I&R 0330T Tear Film Imaging, Uni/Bi, With I&R 0333T Visual Evoked Potential, screening of visual acuity 0341T Quantitative pupillometry, Uni/Bi, With I&R 34 How You Create Your Medical Record Matters! There Are Legal Implications Of How Your Record Your Encounter

10 10 54 Remember The Fundamentals What do you do? (hint think evidence based medicine) What does this patient need? (hint not what do you want to do) What is in the patient s best interest? Medical Necessity Is Services or supplies that are proper and needed for the diagnosis or treatment of the patient s medical conditions, are provided for the diagnosis, direct care and treatment of the patient s medical condition, meet the standards of good medical practice in the local area and aren t mainly for the convenience of the patient or the physician. 55 Source: 56 So What Exactly Does That Mean? The medical record must clearly demonstrate that the service, procedure, or test ordered & performed was absolutely necessary in order to diagnose, treat, or monitor the treatment of the patient s condition.

11 11 57 Keep The Order In Mind - It s As Easy As 1, 2, 3. Using The CPT & ICD System Is A Legal Requirement So learn to do it properly. 1. Always provide the Standard of Care to the patient 2. Tell the medical record what you did and why you did it 3. Then accurately translate what you did with the patient into CPT & ICD language for the insurance carrier and your PM system. Never code first, then do testing just to reach the level that specific code requires This approach would not support the concept of Medical Necessity that is required by third party carrier rules and guidelines E&M Medical Necessity - Medical Necessity of E&M Services Section 1862(a)(1)(A) of the SSA, Exclusions From Coverage and Medicare as Secondary Payer does not include expenses acquired for items and services which are not deemed necessary for the diagnosis or treatment of illness or injury. This applies to all services. CMS IOS Publication , Chapter 12, Section states: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record SERVICE-SPECIFIC PREPAYMENT REVIEWS OF EVALUATION AND MANAGEMENT SERVICES National Government Services will be conducting service-specific prepayment reviews on the following CPT codes targeting E&M services for JK Part B providers: A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred to as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to: Physician/nonphysician practitioner s progress notes, Orders, Medication records, Procedure/operative reports, Relevant diagnostic/operative reports or documentation of time that would assist in supporting the service(s) submitted The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims. Providers can assist in this process by: Reviewing all contractor publications and LCDs Understanding Medicare coverage requirements Ensuring office staff and billing vendors are familiar with claim filing requirements Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request) Ensuring documentation is legible and demonstrates that the patient s condition warrants the services being reported and billed Reports from June 2013 through March 2015 show the following CPT code error rates CPT CODE ERROR RATE (PERCENT) % % % % Posted 05/07/14

12 Office Of Inspector General 2015 Interim Report OIG Report: Documentation Coding Errors Costing Medicare Billions Posted on May 29, 2014 According to a new OIG report, documentation coding errors related to routine patient evaluation and management (E/M) visits are costing Medicare billions of dollars in improper payments a year. The investigation found that nearly $7 billion dollars in improper payments were made in 2010 alone. Most of the losses were the due to bills that were incorrectly coded and/or lacking documentation; 42% of claims for E/M services in 2010 were incorrectly coded and 19% lacked proper documentation. Your Money Is At Risk The government is actively auditing providers and recouped over $4.3 billion in overpayments in Approximately 21% of claims are being over-coded putting your revenue at risk Audits typically find 8% of claims are under-coded leaving money on the table

13 13 Medical Carriers & Medical Necessity Carriers Generally Define It For Us! What happens if the carrier doesn t have a policy? 64 But, sometime carriers will not have a specific policy regarding the indications of medical necessity, nor a list of covered diagnoses or utilization guidelines that you can refer to. When this is the case, then the prevailing CPT definition and guidelines in combination WITH YOUR MEDICAL EXPERTISE become the defensible rule. Or What Happens If The Patient Is Paying? If the patient is paying out of pocket and it is a separate distinct financial transaction where the carrier is NOT involved (i.e. balance billing), then you are free to do what you and the patient agree to.

14 14 Medical Plans Vs. Refractive Plans What s The Difference? Refractive Plans Do patients need a reason to see you? Do they need to have something wrong with them? What conditions have to be met? Policy in force Coverage eligibility Participating provider What about duplicative coverage? Who s choice is it?? My doctor always wants to bill medical if they find something 67 Question: What is the first thing that must be part of every medical visit? Rule Number One Answer: A chief complaint

15 15 Patients Are Not Expected To Be The Expert WE ARE! Why? Think Of The Three E s Education, Expertise & Experience Why Is The Patient In Your Office? There are only THREE ways that the patient ends up in your practice. 1. They initiate the appointment by phone call, , online booking. 2. You initiate the appointment by telling them to return to the office for a specific reason. 3. Other Physician initiates the appointment by telling them to make an appointment for a specific reason. Once we know who initiated the encounter we can now properly determine the Chief Complaint. 77 There Are TWO Ways A Chief Complaint Requirement Is Met Physician Directed (reason for visit) Patient Directed

16 16 78 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the 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 examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the 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 examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 79 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the 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 examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 80

17 17 Does Medical Coding Seem Like A Foreign Language? It Doesn t Have To Be We Just Have To Speak The Language Understanding Code Differences Within the HCPCS system each code subset has it s own implicit purpose and it s own format 83 Key Concepts Term Definition Code Format Ownership HCPCS I CPT 4; Current Procedural Terminology, 4th Edition (HCPCS Level I Codes) Always Five Digits AMA 1 HCPCS II Healthcare Procedural Coding System Level II Codes A V1234 Always Alphanumeric AMA 1 HCPCS III Healthcare Procedural Coding System Level III Codes (Emerging Technology) 1234T Always Alphanumeric AMA 1 ICD 9 CM International Classification of Disease, 9 th Edition Generally Five Digits WHO 2 1: 2:

18 18 Health Care Procedural Coding System (HCPCS) 84 Level One HCPCS Level Two HCPCS Level Three HCPCS CPT Procedural Codes Non-CPT Codes for Materials, Services & PQRS Emerging Technology & Temporary Use Codes Health Care Procedural Coding System (HCPCS) 85 Level One HCPCS Are The CPT -4 Current Procedural Terminology 4th Edition CPT Codes Are Always One Five Digit Code Plus Up To Four, 2 Digit Modifiers Initial Procedure 1st Modifier AB-CD-EF-GH 2nd Modifier Health Care Procedural Coding System (HCPCS) 86 Level Two - National Codes for Materials, Services & PQRS Level Two Codes: 5 Digit Alphanumeric Level II Designation A-V1234

19 19 Health Care Procedural Coding System (HCPCS) Level Three - Emerging Technology Temporary Use Codes 87 Level Three Codes: Category III codes are temporary codes for emerging technology, services, and procedures. Category III codes consist of four numbers followed by the letter "T." Category III Designation 1234T ICD-9-CM International Classification Of Disease Ninth Edition Clinical Modification 97 ICD-9-CM Codes International Classification Of Disease, 9th Edition Owned By The World Health Organization Consistent On A Global Basis Diagnosis Codes: Single 5 Digit Code with Decimal Point Always use highest level of specificity Can Also Be Single Digit

20 20 98 ICD-9-CM Codes The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure List primary diagnosis code first (systemic always first) Keep in mind that ICD-9 rules prevent you from using the patients symptoms as a diagnosis if you know the cause of the symptoms Link specific procedures to appropriate diagnosis on CMS 1500 form Stay away from diagnosis codes: XXX.9 There are still legitimate 3 and 4 digit ICD-9 codes to use ICD-9 Critical Points Having a diagnosis that supports Medical Necessity is REQUIRED for coverage 99 Having ONLY a covered diagnosis is not enough to survive an audit unless you have properly established Medical Necessity in the medical record 103 ICD-10-CM Ready Or Not International Classification Of Disease Tenth Edition, Clinical Modification

21 ICD-10 ICD-10 is used world-wide All major countries use ICD-10 except the US and Italy UK (1995), France (1997), Australia (1998), Germany (2000), & Canada (2001) Published by World Health Organization (WHO) US obligated to classify morbidity statistics with ICD-10 by world treaty What s Different Between ICD-9 & ICD-10? 68,000+ codes Diseases and conditions and causes grouped: Communicable diseases General diseases that affect whole body Local diseases arranged by site Development of diseases Injuries External causes 106

22 22 What s Different Between ICD-9 & ICD-10? Harmonized with other classifications DSM-IV - mental health disorders ICDO-2 - cancer registries Nursing Removed relationships with procedures/procedure codes (in some applications still tied, where appropriate to LCD s) Revised diabetes codes to be consistent with ADA categories 107 What s Different Between ICD-9 & ICD-10 Increased Specificity For: Laterality (differentiation of right versus left versus bilateral) Injury Codes Code extensions for external causes of injury Code extensions for injuries Postoperative complications & phases of treatment Trimester information Alcohol and substance abuse 108 Bottom Line It s Going To Be Different! 109

23 ICD-9 & 10 Partial Code Freeze The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, On October 1, 2012 and October 1, 2013 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases. On October 1, 2015, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. There will be no updates to ICD-9-CM, as it will no longer be used for reporting. this is no longer true as updates will now occur! On October 1, 2015, regular updates to ICD-10 will begin. 503(a) of Pub. L ICD-10-CM Codes (October 1, 2015) An ICD-10 code: Is three to seven digits long Begins with an alphabetic character Has a numeral as the second digit Includes alpha or numeric digits as the third through seventh characters Decimal after first three characters Not case sensitive Pay attention! Watch for Ø for 0 to differentiate from O Has high levels of differentiation of right vs. left vs. bilateral 111 The ICD -10 For The Eyes (Chapter 7) ICD-10 Codes Eye Conditions (Categories) HØØ-HØ5 Disorders of the Eyelid, Lacrimal System, and Orbit H1Ø-H11 Disorders of the Conjunctiva H15-H22 Disorders of the Sclera, Cornea, Iris, and Ciliary Body H25-H28 Disorders of the Lens H3Ø-H36 Disorders of the Choroid and Retina H4Ø-H42 Glaucoma H43-H44 Disorders of the Vitreous Body and Globe H46-H47 Disorders of the Optic Nerve and Visual Pathways H49-H52 Disorders of the Ocular Muscles, Binocular Movement, Accommodation, and Refraction H53-H54 Visual Disturbances and Blindness H55-H57 Other Disorders Of The Eye and Adnexa Intraoperative and Post Procedural Complications and Disorders of the Eye and Adnexa, Not Elsewhere Classified H59 112

24 24 What s Different Between ICD-9 & ICD-10? ICD-9 Format 113 Category Etiology, Anatomical Site, Manifestation ICD-10 Format Category Etiology, Anatomical Site, Manifestation & Severity Extension Structure Of The ICD-10 Diabetic Retinopathy ICD-10 E (Example) Endocrine, nutritional and metabolic diseases E Diabetes mellitus Type 2 diabetes mellitus Type 2 diabetes mellitus with ophthalmic complications 115 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema Some Typical Codes With Contact Lenses 116 ICD-9 Myopia Regular Astigmatism ICD-10 H52.10 Myopia Unspecified eye H52.11 Myopia, Right Eye H52.12 Myopia, Left Eye H52.13 Myopia, Bilateral H Reg. Astigmatism, Right Eye H Reg. Astigmatism, Left Eye H Reg. Astigmatism, Bilateral H Reg. Astigmatism, Unspecified

25 25 Some Typical Codes With Contact Lenses ICD-9 Keratoconus Irregular Astigmatism ICD-10 H Keratoconus, Right Eye H Keratoconus, Left Eye H Keratoconus, Bilateral H Keratoconus, Unspecified Eye H IRR. Astigmatism, Right Eye H IRR. Astigmatism, Left Eye H IRR. Astigmatism, Bilateral H IRR. Astigmatism, Unspecified Structure Of The ICD-10 (Clinical Example Later) The Placeholder Not every ICD-10-CM code with a seventh character has a sixth character or even a fifth or fourth character for that matter The letter x serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The x also allows for future expansion of the codes. When reporting ICD-10-CM codes, a placeholder must be added so the seventh character is in the correct position. Without this placeholder to ensure characters appear in the correct positions, codes are invalid. The location of the X within a code matters. When x is in the fourth, fifth, and/or sixth character, it appears lowercase and is a placeholder. When X is at the beginning of the code, it is uppercase and indicates the chapter 119 Structure Of The ICD-10 (Clinical Example Later) The Seventh Character A - Initial encounter. This describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. So, you can use A as the seventh character on more than just the first claim. In fact, you can use it on multiple claims. D - Subsequent encounter. This describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery. S - Sequela. The seventh character extension S indicates a complication or condition that arises as a direct result of an injury. An example of a sequela is a scar resulting from a burn.

26 26 Related To The Eye, But In Not In Chapter 7 Exclusions: Listed at the beginning of the Eye Chapter (Chapter 7) Indicates condition or disease is found in a different chapter Exclusions can pertain to: conditions during newborn period (PØØ-P96) some infectious and parasitic diseases (AØØ-B99) complications of pregnancy (OØØ-O99) congenital disorders (QØØ-Q99) diabetic and endocrine disorders (EØØ-E9Ø) trauma, injury, and poisoning (SØØ-T98) neoplasms (CØØ-D48) 120 Special Symbols (Dagger & Asterisk) ( ) underlying cause or aetiology (note spelling - Brit.) (*) current manifestation Always code dagger first, then asterisk 122 Clinical Example: Hypertensive retinopathy (H35.Ø3 ) Code I1Ø (Essential (primary) hypertension) first Code H35.Ø33 (hypertensive retinopathy, bilateral) second Additional Circumstances (Injury & Trauma) Chapter 19 Organized by anatomical site, then type of injury 7th character required to specify number of the encounter (initial vs subsequent or follow-up) Need to use Chapter 20 and indicate cause of injury (definite with S code, maybe for T ) 123

27 Eye Injury & Trauma ICD-9 ICD Corneal Foreign Body T15.01XA Foreign Body In Cornea, Right Eye, Initial Encounter T15.01XD Foreign Body In Cornea, Right Eye, Subsequent Encounter T15.01XS Foreign Body In Cornea, Right Eye, Sequela Eye Injury & Trauma ICD-9 ICD Superficial Injury of Cornea S05.01XA Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter 125 S05.01XD Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Subsequent Encounter S05.01XS Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Sequela Eye Injury & Trauma 126 Cause Of Injury (Chapter 20) Tree Branch ICD-10 W22.8XX(A,D, Or S) Striking Against or Struck By Other Objects, Initial (A), Subsequent (D), or Sequela (S) Fingernail W5Ø.4XX(A,D, Or S) Accidental Scratch By Another Person, Initial (A), Subsequent (D), or Sequela (S)

28 28 So, If You Are Coding A Corneal Abrasion Procedures RT Diagnoses During Initial and Active Management S05.01XA Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter W22.8XXA Striking Against or Struck By Other Objects, Initial Encounter Diagnoses During Follow-Up Visits S05.01XD Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter W22.8XXD Striking Against or Struck By Other Objects, Initial Encounter 127 Defining The Physician/Patient Encounter (The #1 Audit Trigger) Office Visits The Ophthalmic Office Visits The Comprehensive Exam & The Intermediate Exam

29 x4 - Comprehensive CPT 2015 Definition: 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 examination Ophthalmological examinations Gross visual fields Basic sensorimotor examination It often includes, as indicated: Biomicroscopy Examination with cycloplegia or mydriasis Tonometry It always includes initiation of diagnostic and treatment programs. 920x2 - Intermediate CPT 2015 Definition: describes an evaluation of a new (condition) or an existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis The service includes: History General medical observation External examination Adnexal examination other diagnostic procedures as indicated It often includes, as indicated: Biomicroscopy And may include the use of mydriasis for ophthalmoscopy It always includes initiation of diagnostic and treatment programs XX & Dilation Dilation Is NOT Mandatory With Any Of The 920XX Codes

30 30 The Evaluation & Management Office Visits They Are NOT New Anymore! Evaluation & Management Coding System 140 New Patient Established Patient Evaluation & Management Coding System 141 New Patient Established Patient

31 31 Evaluation & Management Coding System 142 New Patient The use of & require a comprehensive history which is difficult for us to provide Established Patient provided Use CPT 99211, physician presence is not required, but he/she must have initiated the service as part of a continuing plan and must at least be in the office suite when each service is Elements of E/M Rationale History Examination Medical Decision Making Counseling Coordination of Care Nature of the Presenting Problem Time 144 The Big Three History Four levels of history Physical Examination We are single system subspecialists Four levels of physical examination Medical Decision Making Four levels of medical decision making 145

32 32 Documentation of History Problem Focused Chief Complaint Most Common 1 to 3 elements of History of Present Illness (HPI) Expanded Problem-Focused HPI Elements Chief Complaint Location 1 to 3 elements of HPI Duration Ocular review of systems Severity Detailed Modifying Factors Chief Complaint 4 elements of HPI Ocular review of systems + 1 other system 1 specific item from past, family, or social history Comprehensive Chief Complaint 4 elements of HPI Ocular review of systems Review of at least 9 additional systems 2-3 specific item from past, family, and social history (est. vs. new) 146 Scoring A History - HPI History of Present Illness (HPI) Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Brief elements Extended elements or at least 3 chronic or inactive conditions Scoring A History Review Of Systems Constitutional Eyes Ears, Nose, Mouth & Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Problem Pertinent is 1 system Extended is 2-9 systems Complete is systems How Are You Going To Get To 10?

33 33 Documentation of History Problem Focused Chief Complaint Most Common 1 to 3 elements of History of Present Illness (HPI) Expanded Problem-Focused HPI Elements Chief Complaint Location 1 to 3 elements of HPI Duration Ocular review of systems Severity Detailed Modifying Factors Chief Complaint 4 elements of HPI Ocular review of systems + 1 other system 1 specific item from past, family, or social history Comprehensive Chief Complaint 4 elements of HPI Ocular review of systems Review of at least 9 additional systems 2-3 specific item from past, family, and social history (est. vs. new) J. Rumpakis, OD, MBA Scoring A History - PFSH Past, Family & Social History Patient s Past History Family History Social/Occupational History Problem Pertinent - l question Complete - 2 areas for Est Pt - 3 areas for New Pt Scoring A History Putting The Pieces Together HPI ROS Level 1 Level 2 Level 3 Level 4 Problem Focused Brief 1 3 N/A Expanded Problem Focused Brief 1 3 Problem Pertinent 1 area PFSH N/A N/A Detailed Extended 4 8 Extended 2 9 areas Problem Pertinent 1 area Comprehensive Extended 4 8 Complete areas Complete 2 areas est 3 areas new

34 34 Documentation of Physical Exam Problem Focused Limited exam of the affected body area or organ systems 1 to 5 elements of the eye exam documented Expanded Problem-Focused Limited exam of the affected body area or organ system and other symptomatic or related organ systems 6 elements of the eye exam documented Detailed Extended exam of the affected body area and other symptomatic or related organ systems 9 elements of the eye exam documented (can include M/S) Comprehensive Complete single system specialty exam All elements of the eye exam plus mental status documented 152 Elements Of An Eye Exam (1997) 1. VA s 2. EOM 3. Confrontation Fields 4. Adnexa Lids Lacrimal glands Lacrimal drainage Orbits Preauricular lymph nodes 5. Bulbar and palpebral conjunctivae 6. Corneas Epithelium Stroma Endothelium Tear film 7. Pupils & Irises Shape Afferent pupil Size Morphology 8. Anterior Chamber Depth Cells Flare 9. Lenses Clarity Ant/post caps Cortex Nucleus 10. IOP - except in children and patients with trauma or infectious disease 11. Optic discs Size C/D ratio Appearance Nerve fiber layer 12. Posterior segments Retina Vessels 13. Orientation 14. Mood/Affect 154 Reference: 1997 CMS Evaluation & Management Guidelines 992XX Codes & Dilation Dilation IS Mandatory With The 992XX Code If The Two Retinal Elements Are Used To Count Towards Level Of Physical Exam, Unless Medically Contraindicated

35 Levels Of Physical Exam Remember Key Numbers of 5, 6, 9, or Everything Any 5 elements or less = Level 1 Any 6 8 elements = Level 2 Any 9 13 elements = Level 3 (including mental status) All elements = Level 4 (including mental status) Medical Decision Making Diagnostic & Treatment Options 157 Number of Diagnoses Number of Management Options 1 is Minimal 2-3 is Limited 4-5 is Multiple 6+ is Extensive Medical Decision Making Complexity of Data 158 Diagnostic service ordered, planned, scheduled, or performed Review of diagnostic tests Decision to obtain old records, or take additional history Relevant finding from old records or additional history taken Discussion with other physician Independent interpretation of previously taken images, or studies

36 36 Medical Decision Making Risk Of Complications/Morbidity Minimal - One self limited or minor problem 159 Low - Two or more self limited or minor illnesses; One stable or chronic illness; One acute illness or injury; Uncomplicated injury or illness. Use of OTC medication. Moderate - One chronic illness with mild complications; Two stable chronic Illnesses; An undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury. Prescription medication management. High - One or more chronic illness with severe complications, Acute or chronic illnesses or injuries posing a threat to life, or an abrupt change in neurological status Medical Decision Making Level 1 Level 2 Level 3 Level Straightforward Low Complexity Moderate Complexity High Complexity Number of Diagnostic & Treatment Options Minimal (1) Limited (2 3) Multiple (4 5) Extensive (6+) Amount & Complexity of Data Minimal or None (1) Limited (2 3) Moderate (4 5) Extensive (6+) Risk of Complications &/or Morbidity Minimal 1 self limited Low 2 SL, 1 C, 1A, OTC Moderate 1CwC, 2 C, New, Rx High 1C w/high comp, threat to life 161 Medical Decision Making Level 1 Level 2 Level 3 Level 4 Straightforward Low Complexity Moderate Complexity High Complexity Number of Diagnostic & Treatment Options Minimal (1) Limited (2 3) Multiple (4 5) Extensive (6+) Amount & Complexity of Data Minimal or None (1) Limited (2 3) Moderate (4 5) Extensive (6+) Risk of Complications &/or Morbidity Minimal 1 self limited Low 2 SL, 1 C, 1A, OTC Moderate 1CwC, 2 C, New, Rx High 1C w/high comp, threat to life

37 37 Medical Decision Making Level 1 Level 2 Level 3 Level Straightforward Low Complexity Moderate Complexity High Complexity Number of Diagnostic & Treatment Options Minimal (1) Limited (2 3) Multiple (4 5) Extensive (6+) Amount & Complexity of Data Minimal or None (1) Limited (2 3) Moderate (4 5) Extensive (6+) Risk of Complications &/or Morbidity Minimal 1 self limited Low 2 SL, 1 C, 1A, OTC Moderate 1CwC, 2 C, New, Rx High 1C w/high comp, threat to life 163 Medical Decision Making Level 1 Level 2 Level 3 Level 4 Straightforward Low Complexity Moderate Complexity High Complexity Number of Diagnostic & Treatment Options Minimal (1) Limited (2 3) Multiple (4 5) Extensive (6+) Amount & Complexity of Data Minimal or None (1) Limited (2 3) Moderate (4 5) Extensive (6+) Risk of Complications &/or Morbidity Minimal 1 self limited Low 2 SL, 1 C, 1A, OTC Moderate 1CwC, 2 C, New, Rx High 1C w/high comp, threat to life Medical Decision Making Level 1 Level 2 Level 3 Level 4 Straightforward Low Complexity Moderate Complexity 164 High Complexity Number of Diagnostic & Treatment Options Minimal (1) Limited (2 3) Multiple (4 5) Extensive (6+) Amount & Complexity of Data Minimal or None (1) Limited (2 3) Moderate (4 5) Extensive (6+) Risk of Complications &/or Morbidity Minimal 1 self limited Low 2 SL, 1 C, 1A, OTC Moderate 1CwC, 2 C, New, Rx High 1C w/high comp, threat to life

38 Identifying Level of Service New Patient Must meet or exceed 3 of 3 to qualify for that code level (Grade To Lowest Of Three) History Exam Decision Making Identifying Level of Service Established Patient Must meet or exceed 2 of 3 to qualify for code (Grade To Middle Of Three) History Exam Decision Making Fitting Contact Lenses Traditional Fits CPT: Professional Edition, Pg. 539

39 Traditional Contact Lens Fitting The prescription of contact lens includes specification of optical & physical characteristics. It is NOT a part of the general ophthalmological services. Supply of materials may be reported as part of the service of fitting or may be reported separately using the appropriate supply codes. Follow-up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service (92012). Fitting Codes Traditional Fits prescription CMS National of Average optical and physical characteristics of and fitting of a contact $96.36lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia. This code encompasses all services that are provided up to the point at which you would issue a contact lens prescription, and it is charged at each visit during which a new lens is placed on a patient s eye, or when the fit is altered. It does not include contact lens follow-up care after the lenses have been dispensed. Keep in mind that the modifier -52 should be used if fitting only one eye. Note - This is a change from Fitting Codes Traditional Fits Prescription CMS National Average of optical and physical characteristics $ of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, one eye. CMS National Average Prescription of optical and physical characteristics $ of and fitting of contact lenses, with medical supervision of adaptation; corneal lens for aphakia, both eyes. CMS National Average Prescription of optical and physical characteristics $97.96 of and fitting of contact lenses, with medical supervision of adaptation; corneoscleral lens. 183

40 40 Fitting Codes Traditional Fits (Tech) CMS National Average Prescription of optical and physical characteristics $80.02 of and fitting of a contact lens, with medical supervision of adaptation and direction of fitting by independent CMS National Averagetechnician; corneal lens, both eyes, except for $72.99 aphakia corneal lens for aphakia, 1 eye CMS National Average corneal $91.92 lens for aphakia, both eyes corneoscleral lens CMS National Average $ Fitting Codes modification of contact lenses. CPT CMS National Average defines this code as modification of contact lens (separate $42.56 procedure), with medical supervision of adaptation. This code applies when you polish or modify the parameters of an RGP lens using a contact lens modification instrument. CMS National Average This is a unilateral service; use modifier -50 if done bilaterally. $ Replacement of contact lens 185 Modifier To Note -52 Reduced Services Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. In 2012, the CPT specifically designated -52 as the modifier to use when fitting a unilateral traditional lens in place of RT or -LT 186

41 41 Modifier To Note -22 Increased Procedural Services When the work required to provide a service is substantially greater than typically required, it may be indentified by adding modifier -22 to the usual procedure code. Documentation in the medical record must support the substantial additional work performed This allows us to violate the one price per CPT code rule. This modifier should NOT be appended to an E/M service 187 Material Codes HCPCS Level II V PMMA, Spherical, Per Lens V PMMA, Toric/Prism, Per Lens V PMMA, Bifocal, Per Lens V PMMA, Color Defined, Per Lens V Gas Perm, Spherical, Per Lens V Gas Perm, Toric/Prism, Per Lens V Gas Perm, Bifocal, Per Lens V Gas Perm, EW, Per Lens V Hydrophilic, Spherical, Per Lens V Hydrophilic, Toric/Prism, Per Lens V Hydrophilic, Bifocal, Per Lens V Hydrophilic, EW, Per Lens V Scleral Lens, PMMA, Per Lens V Gas permeable, scleral, per lens V Lens, Other 188 Scleral Shell CMS NCD Policy 80.5 "Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. A scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens which covers only the central non-white area encompassing the pupil and iris. Where an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding orbital tissue. In such a case, the device serves essentially as an artificial eye. In this situation, payment may be made for a scleral shell under 1861(s)(8) of the Act." 189

42 CPT Code Fitting of a contact lens for treatment of ocular surface disease. Please report materials IN ADDITION to this code using either or the appropriate HCPCS Level II material code. This is a UNILATERAL code Please do NOT report and on the same day of service. Fitting A Contact Lens For OSD Rigid gas permeable scleral lens may be considered medically necessary for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions: Corneal ectatic disorders (e.g., keratoconus, keratoglubus, pellucid marginal degeneration, Terrien s marginal degeneration, Fuchs superficial marginal keratitis, post-surgical ectasia); Corneal scarring and/or vascularization; Irregular corneal astigmatism (e.g., after keratoplasty or other corneal surgery); Ocular surface disease (e.g., severe dry eye, persistent epithelial defects, neurotrophic keratopathy, exposure keratopathy, graft vs. host disease, sequelae of Stevens Johnson syndrome, mucus membrane pemphigoid, post-ocular surface tumor excision, post-glaucoma filtering surgery) with pain and/or decreased visual acuity. Fitting A Contact Lens For OSD Rigid gas permeable scleral lens may be considered medically necessary for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions: Corneal ectatic disorders (e.g., keratoconus, keratoglubus, pellucid marginal degeneration, Terrien s marginal degeneration, Fuchs superficial marginal keratitis, post-surgical ectasia); Corneal scarring and/or vascularization; Irregular corneal astigmatism (e.g., after keratoplasty or other corneal surgery); Ocular surface disease (e.g., severe dry eye, persistent epithelial defects, neurotrophic keratopathy, exposure keratopathy, graft vs. host disease, sequelae of Stevens Johnson syndrome, mucus membrane pemphigoid, post-ocular surface tumor excision, post-glaucoma filtering surgery) with pain and/or decreased visual acuity.

43 CPT Code Fitting of a contact lens for management of Keratoconus, Initial Fitting. For subsequent fittings please use either the 9921X or 9201X codes. Please report materials IN ADDITION to this code using either or the appropriate HCPCS Level II material code. MID 2012 CMS & AMA Opinion is now that this code is BILATERAL, not UNILATERAL as originally stated Please do NOT report and on the same day of service. 194 Special Ophthalmological Services

44 The CMS 1500 Form NEW IN 2014 Your LEGAL document submission You are attesting under penalties of perjury that everything is true and accurate Standard format accepted by all carriers for submitting claims Understanding this form is essential to getting properly reimbursed and for following rules in claims submissions. Effective 1/1/2014, Grace Period 1/1 3/31, must use 4/1/2014 Let s Take A Look What Are They? Definition: Describes services in which a special evaluation of the part of the visual system is made, which goes beyond the services included under general ophthalmological services or in which special treatment is given. Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services. 197 CPT: Professional Edition, Pg. 536 Some Frequent Questions! When can I do a special ophthalmic test? You can perform a special ophthalmic test on the same day as any office visit. They are a distinct and separate procedure and are not bundled into any examination services Can I do the tests when the doctor is not in the office? Yes but you do have to pay attention to Supervision Status Can I bill the test on the same day? May have to use a modifier for some carriers Do I have to collect two co-pays? Can I order tests way ahead of time? 198

45 Key Learning Point Interpretation and report by the physician is an integral part of the special ophthalmological services where indicated. Technical procedures (which may or may not be performed personally) are often part of the service, but should not be mistaken to constitute the service itself. New Rule For 2013 Maintained In 2014 & 2015 Self-Referral For Special Ophthalmic Testing C0-16 EOB Claim Designator Requires Physician Name & NPI in Box 17 of CMS 1500 CPT: Professional Edition, Pg Performing Additional Tests Routine Procedures VS. Ordered Procedures The chronology of your medical record is imperative Routine testing = standing orders Never billable Ordered testing Based upon medical necessity Bill with office visit Use modifier when appropriate Be aware of specific code requirements & definitions Generally require an Interpretive Report How Do We Code Something That Is Different Than Its Defined Value? How A Code Is Broken Down Example Computerized corneal topography, unilateral or bilateral, with interpretation and report. (92025 is not used for manual keratoscopy which is part of a single system Evaluation & Management or ophthalmological service). What Coding with modifiers means TC, means you only performed the technical component , means you only performed the professional component 202 CPT: Professional Edition, Pg. 536

46 How A Code Is Broken Down Definitions Modifiers -26 Professional Component, Certain procedures are a combination of the a physician professional component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier -26 -TC Technical Component, The technical component is the equipment and technician performing the test. This is identified by adding modifier TC to the procedure code identified for the technical component charge. Introduced In 2013 Increased In 2015 Multiple Procedure Payment Reduction Summary of Rule: You will get 100% of the highest TC service, but each subsequent TC component will be reduced by 25% for all services performed on the same day. The 2013 Physician Fee Schedule Final Rule indicated that CMS will monitor these tests to identify inappropriate changes in timing of the delivery of these diagnostic tests. In other words, if physicians start changing their practice and billing patterns to avoid the reductions, they will most likely be identified as an outlier which could result in an audit. 204 Why Does This Matter? Let s look at reimbursement issues CPT Code CPT Code Before After MPPR MPPR Professional Component ( 26) $3.28 $20.48 $23.76 $23.76 Technical Component ( TC) $17.62 $17.97 $35.59 $31.19 Total $20.90 $38.45 $59.35 $54.95 Total Reduction In This Example 7% Reimbursement as a whole code is the same as the sum total of both separate components. General rule is that you are prevented from breaking apart if you are doing the test in your office. 205

47 What Codes Are Affected? Patient Notification What It Is And Why We Need It Patient Notification of Services Two Types Of Patient Notification Specific Use For Each The ABN and NEMB ABN - Advance Beneficiary Notice Financial Informed Consent Patient May Pay Patient Signature Required NEMB - Notice Of Exclusion From Medicare Benefits Patient Must Pay excluded benefits Patient Signature NOT Required 208

48 Modifiers For Patient Notification GA Waiver of Liability Statement Issued as Required by Payer Policy GX Notice of Liability Issued, Voluntary Under Payer Policy GY Statutory exclusions GZ Expected Denial, No ABN on file Using The Right Modifier Is Critical -GA indicates that the ABN is required by the payer policy. It is appended to a CPT code to report that a required ABN was issued for a service and is on file. If the service is denied, CMS will assign financial liability to the beneficiary. Because an ABN was properly obtained, the financial liability is legally transferred to the patient and the physician can bill the patient for this service. -GX When modifier GX is appended to a CPT code, it used to report that a voluntary ABN was issued for a service that is statutorily excluded from Medicare reimbursement. Medicare rejects noncovered services appended with GX and assigns liability to the beneficiary. Because this is a voluntary ABN, the patient always has financial responsibility for the procedure or test being conducted J. Rumpakis, OD, MBA Using The Right Modifier Is Critical -GZ indicates that a service or item is expected to be denied as unreasonable or unnecessary. It is appended to a CPT code to report that an ABN was not issued for this service. CMS will automatically deny these services and indicate that the beneficiary is not responsible for payment. Because the doctor did not obtain an ABN prior to performing the service, he cannot bill the patient. -GY When modifier GY is appended to a CPT code to report when a service is specifically excluded by Medicare and an ABN was not issued to the beneficiary. This indicates that the service is statutorily excluded or does not meet the definition of any Medicare benefit. CMS will deny these claims and the beneficiary will be totally responsible for all financial liability J. Rumpakis, OD, MBA

49 The Interpretation & Report Should Contain Indications for testing Whether the test was ordered Test reliability Test results Comparative findings Plan Initiation of diagnostic/treatment plan Doctors signature Corneal Topography Corneal Topography For topography to be filed with an insurance claim, there must be an image of the topography or a topography database and an interpretation or report associated with the medical record. This is classified as an unilateral or bilateral code, which means that each eye is not billed separately using modifiers. Generally, topography needs to be billed with specific diagnoses, such as irregular astigmatism, keratoconus, corneal scar or corneal transplantation. There are a number of other applicable diagnoses, which vary by state and carrier. Anterior Segment Photography External Ocular Photography Although photography is a much better and faster documentation tool than a drawing in the chart, it rarely meets the definition of medical necessity, which means it is almost always payable by the patient and not billable to a medical carrier. There are cases when photography may be necessary to communicate with a lab, capture the details of a fluorescein pattern or document pre-existing conditions, such as corneal scarring, microcystic edema or neovascularization. If medical necessity can appropriately be established, the photos either need to be printed and placed in the patient record, downloaded to the patient s electronic medical record or documented in the patient medical record. The photos must be kept in a separate referenceable database, and a complete interpretative report must be completed. Photography is considered a bilateral procedure, though some carriers do classify it as a unilateral procedure.

50 OCT Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation & Report, Unilateral or Bilateral. Medical necessity must be established in medical record For Tear Film Imaging, use New Code 0330T Endothelial Photography When Is It Necessary? Governed By NCD 80.8 Special Anterior Segment Photography Special Anterior Segment Photography With interpretation and report, including specular endothelial microscopy and cell count. This code is used when performing endothelial cell counts, which are helpful in determining the appropriateness of contact lens fits in sick eyes, such as cases of graft failure or Fuch s dystrophy. According to Medicare guidelines (NCD 80.8), photography of the corneal endothelium is a covered procedure when reasonable and necessary for patients who meet one or more of the following criteria: Slit lamp evidence of endothelial dystrophy (e.g., corneal guttata). Slit lamp evidence of corneal edema. Is to undergo a secondary intraocular lens implantation. Previous intraocular surgery and requires cataract surgery. Evidence of posterior polymorphous dystrophy of the cornea or iridocorneal endothelial syndrome (ICE). To be fitted with extended wear contact lenses after intraocular surgery Is to undergo a surgical procedure associated with a higher risk to corneal endothelium, e.g., phacoemulsification or refractive surgery

51 51 CPT Code Endothelial cell photography is a covered procedure under Medicare when reasonable and necessary for patients who meet one or more of the following criteria: Have slit lamp evidence of endothelial dystrophy (cornea guttata), Have slit lamp evidence of corneal edema (unilateral or bilateral), Are about to undergo a secondary intraocular lens implantation, Have had previous intraocular surgery and require cataract surgery, 218 CPT Code CMS National Average Are about to undergo a surgical procedure associated with a higher risk to corneal endothelium; i.e., phacoemulsification, $38.58 or refractive surgery (see 80.7 for excluded refractive procedures), With evidence of posterior polymorphous dystrophy of the cornea or irido-corneal-endothelium syndrome, or Are about to be fitted with extended wear contact lenses after intraocular surgery. When a pre-surgical examination for cataract surgery is performed and the conditions of this section are met, if the only visual problem is cataracts, endothelial cell photography is covered as part of the presurgical comprehensive eye examination or combination brief/intermediate examination provided prior to cataract surgery, and not in addition to it. (See 10.1.) 219 National vs. Local Policies National National Coverage Determination NCD Local Local Medical Review Policy LMRP Local Coverage Determination LCD 220

52 52 What Is A NCD? An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LMRP). Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claimsprocessing contractors. That issuance, which includes an effective date and implementation date, is the NCD. 221 What Is A LCD? An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary). The difference between LMRP s and LCD s is that LCDs consist only of "reasonable and necessary" information, while LMRP s may also contain category or statutory provisions. 222 Local Carrier Policy Implications Effective Date Indications of Medical Necessity Covered Diagnoses Recording Requirements Utilization Guidelines 223 All Policies Are in CodeSAFEPLUS & Provided In Real-Time You will KNOW if there is a policy at the time of service and EXACTLY was the policy is

53 53 Ultrasonic Procedures CPT Codes General Rules With Ultrasonography All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated. A final written interpretation and report should be issued for inclusion in the patient s medical record. Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and a final written report is not reportable is exempt because it is solely a biometric measurement. Ultrasonic Procedures Quantitative A-Scan Only B-Scan (with or without superimposed non-quantitative A-scan) Anterior Segment Ultrasound, Immersion B-Scan or High Resolution Biomicroscopy 226

54 Be Aware! Of laterality CCI Bundling Edits (office visit) Completeness of medical record Multi Procedure Payment Reduction Let s take a look at as an example Let s Look At Some Cases Keratoconus

55 Keratoconus Diagnosis: 367.1, Myopia Dates of Service Place of Type of Procedures, Services, Supplies Service Service (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/17/ $ /17/ $ Keratoconus Diagnosis: , Keratoconus Dates of Service Place of Type of Procedures, Services, Supplies Service Service (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/31/ $ /31/ $ /31/ V $ Keratoconus Diagnosis: , Keratoconus Dates of Service Place of Type of Procedures, Services, Supplies Service Service (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 2/6/ $

56 Keratoconus Diagnosis: , Keratoconus Dates of Service Place of Type of Procedures, Services, Supplies Service Service (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 4/6/ $ So, What Do We Do With The ICD-10? ICD-9 Keratoconus Irregular Astigmatism ICD-10 H Keratoconus, Right Eye H Keratoconus, Left Eye H Keratoconus, Bilateral H Keratoconus, Unspecified Eye H IRR. Astigmatism, Right Eye H IRR. Astigmatism, Left Eye H IRR. Astigmatism, Bilateral H IRR. Astigmatism, Unspecified Other Corneal Condition

57 57 Other Corneal Condition Diagnosis - Whatever 5 Digit Diagnosis Is Specific To The Patient Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier 1 1/17/ $ /17/ $ /17/ $ /17/ RT - GA 1 $ /17/ V GA (Scleral Lens) 1 $ /17/ V GA (Scleral Cover Shell) 1 $1, Other Corneal Condition Diagnosis - Whatever 5 Digit Diagnosis Is Specific To The Patient Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier 1 2/6/ $ /6/ GA 1 $ Corneal Abrasion

58 Corneal Abrasion Patient Presentation Patient- P.Q. 34 YOAM No Refractive Insurance High Deductible Medical Insurance Wears daily disposable lenses just for sports & going out Thinks he scratched his right eye. Corneal Abrasion Uncorrected VA s: O.D. 20/25 O.S. 20/20 Uncorrected Near VA: O.U. J2 Refraction: O.D. PLANO 0.50 X177 20/20 O.S. PLANO 20/20 Slit lamp shows typical corneal abrasion with fluorescein 240 So what to do you now? What Was 92070? Bandage Contact Lens? Therapeutic Contact Lens? Special Type Of Lens Required? 241

59 What Was 92070? Bandage Contact Lens? Therapeutic Contact Lens? Special Type Of Lens Required? Fitting of a contact lens for medical or therapeutic purposes including supply of lens. As of January 1, Was No Longer A Valid Code (A Unilateral Code) CPT Code Fitting of a contact lens for treatment of ocular surface disease. Please report materials IN ADDITION to this code using either or the appropriate HCPCS Level II material code. This is now thought to be appropriate for a bandage CL situation. Please do NOT report and on the same day of service. 244

60 Corneal Abrasion Diagnosis: 918.1, Superficial Injury of Cornea Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Days or Charges Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/24/ $ /24/ $ The ICD-10 Era Procedures RT 246 Diagnoses S05.01XA Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter W22.8XXA Striking Against or Struck By Other Objects, Initial Encounter Can We Bill For Materials? We are entitled to bill for materials if we are using a revenue based product, however if we are using a non-revenue product such as a trial lens (disposable) as our lens there would be no charge. 247

61 61 Corneal Abrasion Therapeutic Considerations 248 Cycloplegic Antibiotic NSAID Pressure Patch Bandage CL Long Term Hyperosmotics Lubrication therapy Corneal Abrasion Diagnosis: 918.1, Superficial Injury of Cornea Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Days or Charges Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/31/ $ So, If You Are Coding A Corneal Abrasion Procedures Diagnoses During Follow-Up Visits S05.01XD Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter W22.8XXD Striking Against or Struck By Other Objects, Initial Encounter

62 62 $ Corneal Abrasion Health Care Fraud Rules, Damn Rules, & More Damn Rules Who Is The OIG? The Office Of Inspector General

63 The OIG & Their Mission The mission of the Office of Inspector General (OIG), as mandated by Public Law (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. The OIG & Their Mission OIG has a responsibility to report both to the Secretary and to the Congress program and management problems and recommendations to correct them. OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission-related functions performed by OIG components The OIG Work Plan 272 The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging. Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

64 64 Surgical Codes Special Rules & Circumstances CPT Surgical Package Definition The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical One procedure related Evaluation thereby and include, Management on (E/M) a procedure-byprocedure basis, encounter a variety on of the services. date immediately In defining prior the to or specific on the services "included" in a given date of CPT procedure surgical (including code, the history following and physical) services are always included in addition to the operation per se: Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia One related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical) Immediate postoperative care, including dictating operative notes, talking with the family and other physicians Writing orders Typical postoperative follow-up care 274 Global Periods A Global Period is that period of time for which the follow-up care related to the surgical procedure, for that specific interval, is compensated for in the Global payment for the surgical procedure 275

65 Major vs.. Minor Surgery Minor Surgery Any surgical procedure that has a global period of LESS THAN 90 days Major Surgery Any surgical procedure that has a global period of EQUAL TO or GREATER THAN 90 days Surgical Coding CPT Code Group 6XXXX Modifiers Of Special Note For Surgical Procedures -24 Unrelated E/M Service, Same Physician, During Post-Operative Global Period -25 Separate Service, Same Physician, Same Day -50 Bilateral Procedure -51 Multiple Procedures -54 Surgical Care Only -55 Post-Operative Care Only -57 Decision To Perform Major Surgery -67 Repeat Procedure or Service, Same Physician -79 Unrelated Procedure, Same Physician, During Post-Operative Global Period -RT/LT Right, Left -E1 E4 Punctal/Lid Identifiers 279

66 66 Case Presentations Surgical Cases Corneal Foreign Body 282 Corneal Foreign Body Patient Presentation Patient- N.P. 33 YOWM Blue Cross Medical - $2000 Deductible Playing with kid last night in yard wrestling around something got in eye, still there, hurts, light sensitive, more in a.m.

67 Corneal Foreign Body Uncorrected VA s: O.D. 20/30- O.S. 20/20 Uncorrected Near VA: O.U. J2 Slit lamp reveals embedded corneal foreign body at 10:00 O.D., etc 284 Corneal Foreign Body Diagnosis: Corneal Foreign Body, Initial Visit Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Days or Charges Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/24/ $ /24/ $ /24/ $ /24/ $

68 The ICD-10 Era Procedures RT Diagnoses T15.01XA Foreign Body In Cornea, Right Eye, Initial Encounter Cause of injury Place of injury Modifier Significant, separately identifiable E/M service 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 same day. Modifier -25 The OIG Says... We will determine whether providers used modifier 25 appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is unrelated to such procedure or service. 290

69 Let s Look At The Reference OIG Publication On NCCI Edits Specifically calls out Minor Surgical Procedures Modifier -25 So What s Right? Be sure the record is clear regarding the patient complaint, circumstance, finding, result of diagnostic testing, complication, etc that supports the need for a SECOND evaluation and management service. 292 Reference: CMS Rule Corneal Foreign Body Diagnosis: Corneal Foreign Body, Monitoring Visit Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Days or Charges Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 1/31/ $

70 Corneal Foreign Body Diagnosis: Corneal Foreign Body, Monitoring Visit Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Days or Charges Units From To MM/DD/YY MM/DD/YY CPT-HCPCS - Modifier 1 2/24/ $ $ Corneal Foreign Body Amniotic Membranes PROKERA Slim

71 Emerging Paradigm Use PROKERA SLIM to Prevent Progressive Tissue Damage Treat Underlying Pathology Reduce Inflammation AND Stimulate Stem Cell Proliferation Key to minimizing a sightthreatening scar is controlling inflammatory response and promoting healing Promote Regenerative Healing CPT Definition of (Chronological) Placement of amniotic membrane on the ocular surface for wound healing; self retaining Placement of amniotic membrane on the ocular surface for wound healing; self retaining 2013 Placement of amniotic membrane on the ocular surface for wound healing; self retaining 2014 Placement of amniotic membrane on the ocular surface; without sutures Coding For V2790 (amniotic membrane for surgical reconstruction, per procedure) cannot be billed on same day as as it is already included in the reimbursement for the surgical code itself.

72 72 PROKERA Commonly Used ICD-9 Codes ICD-9 To ICD-10 ICD (Neurotrophic Keratoconj) (Corneal Ulcer, unspecified) (KCS, not Sjogren s) (Punctate Keratitis) (Dendritic Keratitis) ICD-10 H16.23 (1,2,3,9) H16.00 (1,2,3,9) H16.22 (1,2,3,9) H16.14 (1,2,3,9) B00.52 Handling Claim Rejections First rule understand what was rejected and why Scope of practice (provider type) Improper code submission With office visit With V2790 Location indicator should be 11 (outpatient office location) Once you understand why the claim was rejected, it is much easier to guide the physician to get reimbursed by properly resubmitting the claim.

73 73 CPT Code Things To Note CPT Characteristics CPT Characteristics Active CMS Code With Reimbursement Bilateral 150% Procedure Total Non-Facility RVU Value = Global Period = 10 Days National Average CMS Reimbursement is $1, LCD s Generally Don t Cover Include Statement Of Medical Necessity & Surgical Report Minor Surgical Procedure Rules 303 Office Visit Related To The Decision To Perform Surgery Is Already Included In Reimbursement For Use of Modifier -25 Should Be Rare Cannot Bill Materials In Addition To Surgical Code V2790 Is NOT Billed In Addition To For CMS, Although Some Other Third Party Carriers May Allow Recurrent Corneal Erosion Recurrent Corneal Erosion Patient Presentation Patient- W.A 67 YOWM Medicare Chief Complaint Left Eye Recurrent episodes of ocular pain Foreign body sensation Photophobia Decreased vision Watering upon awakening 305

74 Clinical Presentation Reduced vision (hazy) Positive staining Hard to hold eye open Epithelial disruption No folds in Descemet s membrane Initial Treatment Protocol Cycloplegia NSAID BCL? 307 Recurrent Corneal Erosion Diagnosis: , Recurrent Erosion Of Cornea Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier 1 1/23/ $ /23/ LT 1 $ Recurrent Corneal Erosion 308 Diagnosis: , Recurrent Erosion Of Cornea Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier 1 1/30/ $ /30/ $ /30/ $

75 Recurrent Corneal Erosion - PROKERA Diagnosis: , Recurrent Erosion Of Cornea Dates of Service Place of Type of Service Service Procedures, Services, Supplies (Explain Unusual Circumstances) Diagnosis Code Charges Days or Units From MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier 1 2/15/ LT 1 $1, The ICD-10 Era ICD Recurrent Erosion Of Cornea 310 ICD-10 H Recurrent Erosion Of Cornea, Left Eye $1, Recurrent Corneal Erosion With PROKERA (CMS)

76 76 My Action Plan What Do I Do Now? Intent vs. Impact We ALL have great intentions! There is often a clear difference that occurs between what you had intended to do and what you actually did Just Do It vs. Just Think About It 314 The Power Of I to the 4 th Power Intent Integrate Impact Implement

77 77 John s 12-Step Program Hi, My Name Is <blank > I am a reformed coder 318 John s 12-Step Program 1. Identify carriers with whom you want to be on their plan it s a business decision! 2. Establish Needs Assessment for your situation Obtain resource material that you need 3. Create disease protocols for your office Review the findings regarding the health and vision of each patient Correspond with the patients PCP regarding your care and the patients condition Develop system for appointing the patients next visit before they leave the office Put the process in flow chart format John s 12-Step Program 4. Everyone in the office must be educated about the protocol and the process All staff must be onboard with providing the highest level of care Diagnosis Treatment Selection of Medication 5. Market your ability to provide primary care to your patient base Set Goals, Objectives, Strategies, and Tactics for what you want to achieve 319

78 John s 12-Step Program 6. Always perform the standard of care as your baseline 7. Document the medical record with your thoughts and impressions 8. Be vigilant about proper coding Perform internal audits on a regular basis Use a grading sheet on a regular basis Keep up with change in coding protocols Develop office strategy for change mgmt John s 12-Step Program 9. Set your fees appropriately to capture maximum allowable Develop appropriate fee schedule to maximize income while maintaining complete compliance 10. Be audit proof 11. Never be complacent! 12. Subscribe to ReimbursementPLUS.com & attend another coding class within the next 6 months stay on top of it! Cracking The Code Clinical Case Management In The ICD-10 Era Contact Lenses John Rumpakis, OD, MBA