Eye Specialty Group. Optometry Reimbursement Updates. Presents: Presented By: Kirk Mack, COMT, CPC, COE, CPMA Senior Consultant

Transcription

1 Eye Specialty Group Presents: Optometry Reimbursement Updates Presented By: Kirk Mack, COMT, CPC, COE, CPMA Senior Consultant February 21, 2015 Memphis, Tennessee

2 SEMINAR: Optometry Reimbursement Updates by Corcoran Consulting Group Ardare Corporation 560 E. Hospitality Lane, Suite 360 San Bernardino, California (800) Copyright 2015 All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the author. From time to time, changes may occur in the content of this material and it is the user's responsibility to assure that current issues of this material are utilized. This additional information is also copyrighted as expressed above. Other copyright: CPT and all CPT codes are copyrighted by the American Medical Association with all the rights and privileges pertaining. Objective: This material is provided as part of course of instruction on current reimbursement regulations and practice management techniques. The user is strongly encouraged to review official instructions promulgated by the Centers for Medicare and Medicaid Services (CMS), and their Medicare administrative contractors; this document is not an official source nor is it a complete guide on all matters pertaining to reimbursement. Disclaimer: The reader is reminded that this information can and does change over time, and may be incorrect at any time following publication.

3 WHAT S NEW?

4 Executive Summary Hot Reimbursement Topics and What s New Corcoran Consulting Group Payment issues New codes Regulatory matters Administrative changes Incentive programs Utilization changes Sustainable Growth Rate (SGR) SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S.2000) bipartisan, bicameral legislation H.R. 4015/S repeals the SGR; institutes a 0.5% update to Medicare physician payments for five years; preserves fee-for-service; Creates a new, non-budget-neutral Merit-Based Incentive Payment System (MIPS) Source: ASCRS 2015 MPFS Protecting Access to Medicare Act (PAMA) 2014 signed in early % PFS update for January 1 March 31, 2015 Conversion factor of $ Without intervention CF drops to $ for April 1 December 31, 2015 RVU changes will occur on January 1, 2015 Correction of CMS error in malpractice RVUs results in reductions of approximately 1% 2% GPCI floor of 1.0 remains through March 31, 2015 Source: CMS 10/31/14 Medicare Conversion Factor Source: CMS 10/31/14; 2015 CF through 3/31/ Relative Value Unit Changes E/M new patient level 3 (99203) 1% Intermediate Eye exam (92012) -1% Comprehensive Eye exam (92014) -2% SCODI ON/retina (92134) -1% Intravitreal injection (67028) -3% Cataract surgery w/iol (66984) -4% Gonioscopy (92020) -4% PPV (67036) -9% Scleral reinforcement w/ graft (67255) -23% PPV w/removal of ILM (67042) -26% PPV w/endolaser PRP (67040) -29% Percentage change from 2014

5 Sequestration Sequestration ordered as of March 1, 2013 Reduces Medicare FFS by 2% Affects providers, facility, and DME Dates of service on or after 4/1/13 Reduction taken after coinsurance and deductible Unassigned claims also subject to reduction Medicare EHR incentive payments reduced by 2% PQRS and E-Rx 2013 incentive payments reduced by 2% Continues through 2023 Payment issues New codes Regulatory matters Administrative changes Incentive programs Utilization changes Executive Summary Source: ASCRS Washington Watch Weekly 3/8/13; Announcement NPC-Call.pdf New / Deleted CPT Codes New Category III Codes Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report Replaces 0181T 0341T 0356T Quantitative pupillometry with interpretation and report, unilateral or bilateral Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each Reimbursed in HOPD and ASC as of July 1, 2014 Source: AMA CPT 2015 Source: AMA CPT 2015 New Category III Codes New Category III CPT Code 0378T Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 0380T Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report 0379T technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional Source: AMA CPT 2015 Source: AMA CPT 2015

6 CPT Clarification Scanning laser ophthalmoscopy (SLO) Quantified data use or Photographic image only use ICD-10-CM Deadline Final rule for adoption of ICD-10-CM Published in January 16, 2009 Federal Register (45 CFR part 162) Original Compliance date was October 1, 2013 Delayed until October 1, 2014 H.R Protecting Access to Medicare Act of 2014 Introduced 3/26/14 by Rep. Pitts (R-PA) Passed Senate 3/31/14, Signed by President on 4/1/2014 Became Public Law Source: CPT Assistant, Nov 2014 Source: CONGRESS.GOV ICD-10 Delayed Again March 31, HR 4302 signed by President Obama SGR formula temporary fix ICD-10 delayed The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard code sets under section 1173(c) of the SSA and section of 45CFR Payment issues New codes Regulatory matters Administrative changes Incentive programs Utilization changes Executive Summary Targets for Scrutiny 2015 OIG Work Plan Place of Service Errors Payments for drugs Ambulatory Surgical Centers Payment System Ophthalmological Services Questionable billing during 2012 Imaging services Payments for Practice Expense Medicare Incentive Payments for Adopting Electronic Health Records Anesthesia services Payments for personally performed services Payment for compounded drugs under Medicare Part B Security of Certified Electronic Health Record Technology under Meaningful Use Source: HHS OIG FY 2015 Work Plan 2015 Part B Annual Deductible Medicare Part B deductible $147 Unchanged from 2013 / 2014 Effective date 1/1/15 Source: CMS

7 Medicare Premiums Levels of Appeal Source: HHS.gov Press release 10/9/ Part A Deductible $1,184 $1,216 $1,260 Part B Premium $ $ $ Co-insurance/day for inpatient stay, days $296 $304 $315 Co-insurance/day for inpatient stay, days >90 $592 $608 $630 Process Days to File Time Limit AIC 1 Redetermination 120 days 60 days $0 Reconsideration 180 days 60 days $0 ALJ 60 days 90 days $150 Department Appeals 60 days 90 days $0 Board Federal District Court 60 days NA >$1,460 1 Amount in controversy; ALJ increased $10 from 2013; Federal Court increased $30 from 2014 Source: Grievances/OrgMedFFSAppeals/index.html The Physician Payments Sunshine Act Requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal health care programs to report certain payments and items of value given to physicians and teaching hospitals. Initial reporting period was August 1, 2013 December 31, 2013 Subsequent reporting periods will be annual Public release date September 30, 2014 The Physician Payments Sunshine Act Preparations 1. Register on CMS website to verify data 2. Track internally payments and items of value received and by whom 3. Be prepared to discuss this with patients Source: Source: Guidance/Legislation/National-Physician-Payment-Transparency- Program/index.html OIG Report on E / M Services May 29, 2014 release of report titled: Improper payments for evaluation and management services cost Medicare billions in 2010 Improper payments of $6.7 billion 42% of claims were incorrectly coded Included both upcoding and downcoding 19% of claims lacked documentation Improper Medicare FFS Payments FY 2014 Part A & B improper payments totaling $45 billion; 12.7% of the dollars processed by CMS Part C error rate 9% Medicaid error rate is 6.7% Source: Source:

8 Medicare Error Rate ( ) Recovery Audit Program FY 2010 Oct 2009 Sept 2010 FY 2011 Oct 2010 Sept 2011 FY 2012 Oct 2011 Sept 2012 FY 2013 Oct 2012 Sept 2013 Total National Program Overpayments Collected Underpayments Collected $75.4M $797.4M $2,291.3M $3,656.8M $6.8B $16.9M $141.9M $109.4M $167.2M $435.4M Total Corrections $92.3M $939.3M $2,400.7M $3,823.8M $7.26B Source: CMS Medicare Fee-for Service RAC Program FY 2013 Recovery Audit Contractors Update CMS announced pause in operations on February 18, 2014 Some automated reviews restarted in August 2014 CMS negotiating new contracts for RACs Expect changes in the program Name change to Recovery Auditors (RA) Payment issues New codes Regulatory matters Administrative changes Incentive programs Utilization changes Executive Summary Source: Systems/Monitoring-Programs/Medicare-FFS-Compliance- Programs/Recovery-Audit-Program/Recent_Updates.html CMS Incentive Programs Physician s Quality Reporting System (PQRS) Value-based Payment Modifier (VM) Health Information Technology (HIT) Incentives PQRS PPACA made PQRS mandatory by 2015 Bonus payment for 2014 = 0.5%, end of bonuses Punitive (-1.5%) if not participating in 2015; -2% in 2016 and beyond Source: Patient Protection & Affordable Care Act (PPACA)

9 PQRS 2015 Options Report at least 9 measures via claims and registry-based reporting covering at least 3 National Quality Strategy (NQS) domains Include 1 measure from cross-cutting measure set (New) Report 1-8 measures if less than 9 apply Measure Applicability Validation (MAV) process initiated Report each measure for at least 50% of the Medicare Part B FFS patients claims based or with a registry Participate in a qualified clinical data registry Source: CMS Fact sheet 10/31/14; CMS 1612-FC PQRS 2015 CMS ophthalmic measures Primary Open Angle Glaucoma: Optic nerve head evaluation (#12) AMD: Dilated macular examination (#14) Diabetic Retinopathy: Documentation of presence or absence of macular edema and level of severity of retinopathy (#18) Diabetic Retinopathy: Communication with the physician managing ongoing diabetes care (#19) Eye Exam in Diabetic Patient (#117) Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement (#140) Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care (#141) Source: CMS 1612-FC Cross-cutting Measure Set Extensive list Applicable for ophthalmology and optometry Tobacco Use Screening and Cessation Intervention (#226) Documentation of Current Medications in the Medical Record (#130) Preventive Care and Screening: Influenza Immunization (#110) (Jan March / Sept Dec) Pneumonia Vaccination Status for Older Adults (#111) New Measures PQRS 2015 Registry Reporting only Adult Primary Rhegmatogenous Retinal Detachment Repair Success Rate (#384) % of surgeries where retina remains attached after only one surgery Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate (#385) % of retinal detachment cases achieving flat retinas six months post-op Source: CMS 1612-FC Source: CMS 1612-FC New Measures PQRS 2015 Registry and Measure Group only Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) (#388) Cataract Surgery: Difference Between Planned and Final Refraction (#389) % of patients who achieve planned refraction within +/- 1.0D Source: CMS 1612-FC PQRS 2015 Cataracts Measures Group Increased requirement to all eight measures Report for 20 patients, 11 must be Medicare Reportable by Registry only #191 Cataracts: 20/40 or Better Visual Acuity within 90 days Following Cataract Surgery #192 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures #303 Cataracts: Improvement in Patient s Visual Function within 90 Days Following Cataract Surgery #304 Patient Satisfaction Within 90 Days Following Cataract Surgery Source: CMS 1612-FC

10 PQRS 2015 Cataracts Measures Group New additions to Cataracts measures Group #388 Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) Registry only #389 Cataract Surgery: Difference Between Planned and Final Refraction Registry only #130 Documentation of Current Medications in the Medical Record #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Avoiding 2017 PQRS Penalty Satisfy reporting requirements for the 2015 PQRS program No alternative reporting options as in 2013 and 2014 to avoid penalties in 2015 and 2016 PQRS penalty for 2017 is 2% reduction for PQRS and 2% - 4% for VBM program Source: CMS 1612-FC Value-based Payment Modifier Provides for differential payment to a physician or group under the MPFS based upon the quality of care furnished compared to cost during a performance period. Program in effect for groups of >10 in 2016; based on 2014 performance Program in effect for all providers in 2017; based on 2015 performance Based on participation in PQRS program Source: Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifi er.html Quality Resource Use Reports QRUR is confidential feedback report for those billing fee-for-service Clinical quality measures derived from claims Individual physician performance on quality measures Overall costs for patients whose care a physician directed, contributed to or influenced Per capita costs for patients with diabetes, coronary artery disease, chronic obstructive pulmonary disease and heart failure QRURs contain quality of care and cost performance rates on measures that will be used to compute the value based payment modifier Sources: Payment/PhysicianFeedbackProgram/2012-QRUR.html Potential Financial Penalties CY 2014 is the performance period for the Value Modifier that will be applied in CY In order to avoid an automatic negative two percent ( -2.0% ) Value Modifier payment adjustment in CY 2016, EPs in groups of 10 or more MUST participate in and satisfy the Physician Quality Reporting System (PQRS) requirements as a group or as individuals in CY 2014 Value Modifier Payment Adjustments In CY 2017, CMS will apply a maximum downward adjustment of -2.0 percent for groups with two to nine EPs and solo practitioners, if the group or solo practitioner does not meet the quality reporting requirements for the PQRS. Source: Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html Source: sheets/2014-fact-sheets-items/ html?dlpage=1&dlsort=0&dlsortdir=descending

11 Value Modifier Payment Adjustments...for CY 2017 payments, a -4.0 percent Value Modifier adjustment will apply to groups of ten or more EPs subject to the Value Modifier that do not meet the quality reporting requirements for the Physician Quality Reporting System (PQRS). VBPM 2015 Solo providers and Groups with < 10 EPs Cost / Quality Low Quality Average Quality High Quality Low Cost +0.0% +1.0x +2.0x Average Cost +0.0% +0.0% +1.0x High Cost +0.0% +0.0% +0.0% Source: sheets/2014-fact-sheets-items/ html?dlpage=1&dlsort=0&dlsortdir=descending X represents payment adjustment factor which will be determined at the end of CY 2015 ASCRS / ASOA & AAO VBPM 2015 Groups with > 10 EPs Cost / Quality Low Quality Average Quality High Quality Low Cost +0.0% +2.0x +4.0x Average Cost -2.0% +0.0% +2.0x Health Information Technology (HIT) Component of the American Recovery and Reinvestment Act Penalties begin in 2015 if not participating Requires meaningful use of healthcare IT Certified EHR technology Information exchange Reporting of measures using EHR High Cost -4.0% -2.0% +0.0% X represents payment adjustment factor which will be determined at the end of CY 2015 ASCRS / ASOA & AAO Timeline Began in 2011 and will continue through Last year to begin participation was To qualify for EHR incentive payments, must successfully demonstrate and attest to meaningful use for each year of participation. EHR Incentive Program Medicare Incentive Payments *Program-to Date Providers Paid *Program-to Date Payment Amount Total Eligible Professionals 483,167 $6.47B Ophthalmologists 12,945 $187M Optometrists 21,394 $261M *Medicare payments began in May 2011; information as of September 2014; Source:

12 Financial Penalties Financial Penalties Percentage adjustment assuming less than 75% of eligible professionals are meaningful users Percentage adjustment assuming more than 75% of eligible professionals are meaningful users Eligible professional is not subject to the payment adjustment for the e-rx in % 98% 97% 96% 95% 95% Eligible professional is not subject to the payment adjustment for the e-rx in % 98% 97% 97% 97% 97% Eligible professional is subject to the payment adjustment for the e-rx in % 98% 97% 96% 95% 95% Eligible professional is subject to the payment adjustment for the e-rx in % 98% 97% 97% 97% 97% Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals Last Updated: March 2014 Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals Last Updated: March 2014 Stages of Meaningful Use Year Source: If you were scheduled to demonstrate: Stage 1 in 2014 Stage 2 in 2014 Changes to Meaningful Use You are able to attest for MU: Using 2011 Edition CEHRT to do: 2013 Stage 1 objectives and measures 2013 Stage 1 objectives and measures Using 2011 & 2014 Edition CEHRT to do: 2013 Stage 1 objectives and measures -or Stage 1 objectives and measures Source: Using 2014 Edition CEHRT to do: 2014 Stage 1 objectives and measures 2013 Stage 1 objectives and measures 2014 Stage 1 -OR- objectives and 2014 Stage 1 objectives measures and measures -OR- -OR- Stage 2 objectives and Stage 2 objectives and measures measures Hardship Exceptions Infrastructure: Eligible professionals must demonstrate that they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband). New Eligible Professionals: Newly practicing eligible professionals who would not have had time to become meaningful users can apply for a 2-year limited exception to payment adjustments. Thus eligible professionals who begin practice in calendar year 2015 would receive an exception to the penalties in 2015 and 2016, but would have to begin demonstrating meaningful use in calendar year 2016 to avoid payment adjustments in Hardship Exceptions Unforeseen Circumstances: Examples may include a natural disaster or other unforeseeable barrier. Patient Interaction: Lack of face-to-face or telemedicine interaction with patient Lack of follow-up need with patients Practice at Multiple Locations: Lack of control over availability of CEHRT for more than 50% of patient encounters 2014 EHR Vendor Issues: The eligible professional s EHR vendor was unable to obtain 2014 certification or the eligible professional was unable to implement meaningful use due to 2014 EHR certification delays.

13 EMR, MU2, and Scribes Meaningful Use Core Measure 1 A licensed healthcare professional enters orders into an electronic medical record for purposes of satisfying CPOE objective in MU2, or A credentialed medical assistant enters medication (>60%), radiology (>30%), and laboratory (>30%) orders into EHR to satisfy MU2 thresholds COA, COT, COMT, CO, CMA are certified and credentialed medical assistants ACMSS certified scribe (CMSS) AAMA credentialed scribe for assessment-based recognition in order entry Source: CMS, MU2 Measure 1, October 2012 Official CMS EHR Website Description of Incentive Program Calendar of important dates Official information CMS.gov Regulation & Guidance EHR Incentive Guidance/Legislation/EHRIncentivePrograms/index. html?redirect=/ehrincentiveprograms/30_meaningf ul_use.asp 56 Payment issues New codes Regulatory matters Administrative changes Incentive programs Utilization changes Executive Summary Changes to Practice Patterns Optometry (41) Increases ERG (92275) +7927% Tear osmolarity (83861) +387% VEP (95930) +111% OCT, anterior (92132) +30% OCT, retina (92134) +19% B-Scan (76512) +18% Topography (92025) +11% Decreases Nursing home (99310) -15% Level 5 E/M (992x5) -11% Source: CMS data 2012 vs. 2013, 41 - Optometry Top 10 Optometric Procedures Medicare Utilization Patterns Optometry (41) Rank CPT Procedure Rank CPT Procedure Fundus Photo EO, subsequent Perimetry Gonioscopy SCODI nerve Punctum plug SCODI macula External photo Summary 2015 reimbursement rates minimally changed for first quarter Several code changes More scrutiny of Medicare program integrity Numerous administrative changes Continued growth in many ophthalmic services EO, initial Pachymetry Source: CMS data 2013, 41 - Optometry

14 DIAGNOSTIC TESTS

15 Outline Diagnostic Test Challenges 1. Supervision 2. Interpretation and Report 3. Case studies Kirk A. Mack, COMT, CPC, COE Senior Consultant Corcoran Consulting Group Common Ophthalmic Tests Medicare Utilization Patterns (41 - Optometry) CPT Procedure λ CPT Procedure λ Fundus Photo 13% Scanning Laser 6% (glaucoma) 9208x Perimetry 10% Scanning Laser 5% (retina) 9222x Ext Ophthalmoscopy 6% External Photo 1% Gonioscopy 2% Pachymetry 1% Supervision General supervision Physician reviews notes Direct supervision Physician immediately available Personal supervision Physician in the room Frequency is per 100 office visits (%) on Medicare beneficiaries Source: CMS data (2013), 41 Optometry General Supervision Perimetry Fundus photography External ocular photography Scanning computerized ophthalmic diagnostic imaging Orthoptics Extended color vision testing Dark adaptation exam Visual evoked potential (VEP) done by certified tech A-scan biometry Specular endothelial microscopy and cell count Pachymetry Source: CMS MPFS Direct Supervision Fluorescein angiography ICG angiography A-scans (tumors) Immersion B-scan, high resolution biomicroscopy Contact B-scan Visual evoked potential (VEP) done by non-certified tech Electro-oculography (EOG) Electroretinography (ERG) Source: CMS MPFS

16 Personal Supervision Oculoelectromyography (OEM) Medicare Test Policy 42 CFR Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Source: CMS MPFS Diagnostic Test Order Tests are ordered by the physician for a medically appropriate reason, generally after the eye exam Technicians cannot order tests Order may be scribed by staff on physician s direction VF for COAG next visit per Dr. Smith Standing orders are not reimbursed What s Appropriate? Dr. Optometry instructs the technician to dilate all new patients upon arrival and perform: OCT of optic nerve OU, FP OU, and 24-2 HVF. Which of the following apply? a) These tests are billable only if the physician in the office b) The physician has given standing orders c) The tests cannot all be performed on the same day d) Reimbursement depends on the interpretation of each test What s Appropriate? Dr. Optometry instructs the technician to dilate all new patients upon arrival and perform: OCT of optic nerve OU, FP OU, and 24-2 HVF. Which of the following apply? b) The physician has given standing orders Testing During Postop Period Services not included in the global surgery package: Diagnostic tests and procedures, including diagnostic radiological procedures Examples: Testing unrelated to the prior surgery Testing to evaluate an unfortunate outcome Testing to prepare for another surgery Not covered: testing to confirm the expected outcome Source: MCPM, Chapter 12, 40.1B

17 Six weeks after a cataract surgery, the co-managing optometrist orders an OCT to confirm CME. The OCT shows CME. The tests are not part of the global package and are billable. a) True b) False Testing Following Surgery Testing Following Surgery Six weeks after a cataract surgery, the co-managing optometrist orders an OCT to confirm CME. The OCT shows CME. The tests are not part of the global package and are billable. a) True Chart Documentation.with interpretation and report Interpretation & Report Carriers generally distinguish between an interpretation and report of an x-ray or an EKG procedure and a review of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete written report similar to that which would be prepared by a specialist in the field does not meet the conditions for separate payment of the service. This is because the review is already included in the E/M payment. Source: CMS MCPM Chapter 13, 100 Interpretation & Report For example, a notation in the medical records saying fx tibia or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An interpretation and report should address the findings, relevant clinical issues, and comparative data (when available). Test Interpretation What does it show? Increased blind spot What does it mean? Progression of glaucoma What are you going to do about it? Add a medication Source: CMS MCPM Chapter 13, 100

18 Visual Field Interpretation Plan: Threshold perimetry to re-evaluate POAG October 10, 2012 Mary Smith, COA 1 false positive Good patient cooperation Arcuate scotoma, OU POAG, shows progression since last visit Add another anti-glaucoma medication I. C. Better, O.D. Illustrative Test Interpretation TEST: Visual Field Humphrey 24-2 Interpretation: Stable VF What s wrong? Dx: POAG Illustrative Test Interpretation TEST: Visual Field Humphrey 24-2 Illustrative Test Interpretation TEST: Visual Field Humphrey 24-2 for Glaucoma Interpretation: Stable VF Dx: POAG What does stable mean? Compared to what? Previous test findings? Interpretation: Enlarged blind spot OD. No change from previous visual field 6 months ago. Continue current treatment. Dx: POAG Improved Interpretation Illustrative Test Interpretation TEST: Optic nerve OCT Illustrative Test Interpretation TEST: Optic nerve OCT Interpretation: Normal Dx: POAG What s wrong? Interpretation: Normal Dx: POAG Why was test done? Observations? Data?

19 Illustrative Test Interpretation TEST: Optic nerve OCT Illustrative Test Interpretation TEST: Optic nerve OCT Interpretation: OCT for POAG. No retinal nerve fiber layer loss or changes at this time. No treatment indicated. Interpretation: POAG OU Dx: POAG What s wrong? Dx: POAG Improved Interpretation Illustrative Test Interpretation TEST: Optic nerve OCT Illustrative Test Interpretation TEST: Optic nerve OCT Interpretation: POAG OU Dx: POAG What does the OCT show? Interpretation: Reduced NFL, inferior and nasal quadrants OD>>OS. Progression OD>OS over 6 mo. Add a medication. Dx: POAG Improved Interpretation Illustrative Test Interpretation TEST: Macula OCT Illustrative Test Interpretation TEST: Macula OCT Interpretation: Dx: Dry AMD OD Wet AMD OS CMT* 183 OD CMT* 245 OS What s wrong? Interpretation: Dx: Dry AMD OD Wet AMD OS CMT 183 OD CMT 245 OS What do 183 & 245 mean? Compared to past tests? *CMT = Central Macula Thickness

20 Illustrative Test Interpretation TEST: Macula OCT Illustrative Test Interpretation TEST: Corneal Pachymetry Interpretation: OCT OU to follow AMD. OD dry AMD no edema, CMT stable with previous test. OS Wet AMD with edema. CMT worse from previous test. Refer to Dr. Retina. Dx: Dry AMD OD Wet AMD OS Improved Interpretation Interpretation: Dx: POAG What s wrong? Illustrative Test Interpretation TEST: Corneal Pachymetry Illustrative Test Interpretation TEST: Corneal Pachymetry for Glaucoma Interpretation: What do the Readings mean? Interpretation: 554 OD, 548OS Average Corneal thickness. IOP as stated. Dx: POAG Dx: POAG Improved Interpretation Test Interpretation Create a template/form for diagnostic tests Paper or EMR require the same information Follow same approach for dictation Separate interpretation for each test Separate interpretation for each eye for unilateral tests 92225, Question Q: How many OCTs can I order per year with Glaucoma and Retina pathology?

21 Medicare s Coverage Policy SCODI-P for Optic Nerve Preglaucoma or mild damage Early detection of glaucoma One test per year Moderate damage One or two tests per year 1 Advanced damage Rare indication for SCODI Not more than 4 VFs per year Source: Sample LCD Medicare s Coverage Policy SCODI-P for Retina "It is expected that no more than four (4) tests per year would be appropriate with the following exceptions. Patients with retinal conditions undergoing active intravitreal drug treatment may be allowed one scan per month per eye. These conditions include age-related macular degeneration (wet), choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and non-proliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema. In addition, other conditions which may undergo rapid clinical changes monthly requiring aggressive therapy and frequent follow-up, such as macular hole and traction retinal detachment, may also require monthly scans." Source: Sample LCD Medicare s Coverage Policy Posterior Segment OCT (92133/92134) Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases which involve changes in the optic nerve, subretinal and intraretinal changes, vitreo-retinal relationships and changes in the nerve fiber layer. Diagnose early glaucoma and monitor glaucoma treatment Differentiate causes of other optic nerve disorders when a diagnosis is in doubt. Diagnose and manage the patient's condition when visual field results are insufficient; or when reliable visual field testing cannot be performed, due to visual, physical, mental, or age constraints. Differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields. Detect further loss of optic nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss. Follow glaucoma suspects Question Q: Can we take baseline fundus photos of diabetic patients without retinopathy? A: No Source: Sample LCD Medicare s Coverage Policy Fundus Photography Fundus photography is usually medically necessary no more than two times per year. Fundus photography of a normal retina will be considered not medically necessary. Services exceeding these parameters will be considered not medically necessary. Question Q: Can you bill for extended ophthalmoscopy (92225/92226) with EHR if you do not draw? Source: Sample LCD

22 Medicare s Coverage Policy 9222x Extended Ophthalmoscopy Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report. It is most frequently performed utilizing an indirect lens If indirect ophthalmoscopy is done without a drawing or does not meet the standards indicated, the service is not separately payable and will be considered part of a general ophthalmologic exam ( ) or E&M service. Source: Sample LCD

23 ICD-10 UPDATE

24 ICD-10-CM Deadline ICD-10-CM Overview Kirk A. Mack, COMT, COE, CPC, CPMA Senior Consultant Corcoran Consulting Group Final rule for adoption of ICD-10-CM Published in January 16, 2009 Federal Register (45 CFR part 162) Original Compliance date was October 1, 2013 Delayed until October 1, 2014 H.R Protecting Access to Medicare Act of 2014 Introduced 3/26/14 by Rep. Pitts (R-PA) Passed Senate 3/31/14, Signed by President on 4/1/2014 Became Public Law Source: CONGRESS.GOV House Resolution 4302 SEC DELAY IN TRANSITION FROM ICD 9 TO ICD 10 CODE SETS. The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD 10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d 2(c)) and section of title 45, Code of Federal Regulations. ICD Updates October 1, 2014 and October 1, 2015 only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases No updates to ICD-9-CM, as it will no longer be used for reporting to HIPAA-covered entities October 1, 2016 regular updates to ICD-10 will begin Source: H. R Source: ICD-10 Test Claims Weeks Compare and Contrast Three week-long testing dates November 17 21, 2014 March 2 6, 2015 June 1 5, 2015 Physicians, other providers, DME, HH Submit with current DOS Subject to existing NPI validation edits MACs CEDI will have staff available to answer calls Claims receive acknowledgement codes: 277CA if received AND accepted 999 received BUT rejected No Remittance advice generated Source: MedLearnMatters, MM 8858, 8/22/14 ICD-9 17 Chapters 14,000 codes 3-5 digits First digit is numeric or alpha (E or V) Digits 2-5 are numeric ICD Chapters ~ 69,000 codes 3-7 digits Digit 1 is alpha Digit 2 is numeric Digits 3-7 are alpha or numeric (alpha digits are not case sensitive)

25 ICD-10 Example Nuclear sclerotic cataract (senile) H25.1 Age-related nuclear cataract Cataracta brunescens Nuclear sclerosis cataract H25.10 Age-related nuclear cataract, unspecified eye H25.11 Age-related nuclear cataract, right eye H25.12 Age-related nuclear cataract, left eye H25.13 Age-related nuclear cataract, bilateral Tabular List Categories 3 characters Chapter 7 Disorder of the Eye and Adnexa (H00-H59) Subcategories 4 th character further defines site, etiology, manifestation or state of disease or condition 5 th & 6 th character increases specificity Tabular List 7 th Character Extension 7 th Character Extension Some categories have applicable 7 th characters Last character If code is not six digits, use x as placeholder x as placeholder For when characters are needed for expansion A D S initial encounter subsequent encounter sequela Example Corneal Abrasion Example Corneal Abrasion Category Chapter 19 Injury, Poisoning... S05 Injury of eye and orbit Subcategory 5 th S05.0 Injury of conjunctiva and corneal abrasion without foreign body Specificity x 7 th S05.01 Injury of conjunctiva and corneal abrasion without foreign body right eye Valid code S05.01xA -- Injury of conjunctiva and corneal abrasion without foreign body right eye; initial encounter

26 7 th Character Extension For glaucoma staging, 7 th denotes severity of disease 0 = unspecified (not noted in chart) 1 = mild 2 = moderate 3 = severe 4 = indeterminate (unknown) Example: Glaucoma Staging 7th character is to be assigned to each code in subcategory H40.12 to designate the stage of glaucoma Low-tension Glaucoma H40.12 Low-tension Glaucoma, bilateral (cannot stop here!) H Low-tension Glaucoma, right eye, moderate stage H Low-tension Glaucoma, left eye, severe stage H Laterality Right and left designation 1 = right 2 = left 3 = bilateral 0 or 9 = unspecified Terminology Laterality Example H25.11 Age-related nuclear cataract, right eye H25.12 Age-related nuclear cataract, left eye H25.13 Age-related nuclear cataract, bilateral H25.10 Age-related nuclear cataract, unspecified eye Terminology Laterality Exception example (diseases of eyelids) H Cicatricial entropion of right upper eyelid H Cicatricial entropion of right lower eyelid H Cicatricial entropion of right eye, unspecified eyelid H Cicatricial entropion of left upper eyelid H Cicatricial entropion of left lower eyelid H Cicatricial entropion of left eye, unspecified eyelid H Cicatricial entropion of unspecified eye, unspecified eyelid Ch. 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) Diabetes mellitus Combination codes that include Type of diabetes mellitus Body system affected Complications affecting body system Sequenced based on reason for encounter

27 Diabetes Mellitus Five diabetes mellitus categories E08 Diabetes mellitus due to an underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus Diabetes Mellitus Insulin use All categories except E10 (Type 1 DM) require use of additional code to indentify any insulin use Z79.4 Long term (current) use of insulin *Use E11 if record does not indicate type of DM, but does indicate insulin use. Sources: 1. ICD-10 Official Guidelines, Sect C Chapter specific guidelines; 4.a.3 Compare and Contrast ICD-9 Example: Mild NPDR, no DME DM with ophthalmic manifestation, not stated as uncontrolled ICD-10 Example: Type II DM with mild NPDR w/o macular edema - E Diabetes Mellitus Examples E11.9 Type 2 DM without complications E Type 1 DM with moderate NPDR without macular edema E Z79.4 Type 2 DM with mild NPDR with macular edema & Long-term current use of insulin (if documented) Documentation Upgrade Begin now Review notes for services previously coded and billed Determine if notes are is adequate to support an ICD-10 selection Use your findings to make changes Forms and templates Patient interviews Technician, scribe and physician documentation Documentation Considerations Laterality Is your assessment specific to which eye or eyelid? Etiology / Manifestation Does your chart note list both the disease and the associated manifestation? Specificity Is the impression as specific as possible for a particular condition?

28 Documentation Considerations History Old Diabetic Cataract OD from injury Hypertension HIV positive New Type II diabetes on insulin Cataract OD caused by driver side airbag Hypertension; history of tobacco use Asymptomatic HIV Old Chalazion OS BDR OU Documentation Considerations Impression Iritis OU Hyphema OD No maculopathy New Chalazion LLL Type II diabetes with mild NPDR w/out macula edema; taking insulin Chronic iritis OU Traumatic hyphema OD RA taking plaquenil; no ocular disease Common Patient Syndromes Key Points in Preparation R46.0 Low level of personal hygiene R19.6 Halitosis (bad breath) CMS files / GEMS files Smart Phone or tablet apps Websites Text book (be sure it s 2013 or later) GEM General Equivalence Mappings GEM file is NOT a crosswalk, it is a mapping Two sets of files ICD-9 to ICD-10 ICD-10 to ICD-9 Each file contains code pairs one from each set Expect annual update of files Eye codes translation is fairly straightforward GEM File Layout Senile Cataract Example I-9 I-10 + Flags H H H H H H H H in the first position in flag column = approximate

29 Useful Aids Apps Apple iphone and ipad Android (phone and tablet) Windows Phone Popular options from previous attendees ICD-10 Find-A-Code icd10data Supercoder.com Other Useful Aids AAPC Code Translator Others Transitioning to ICD Notify everyone that this is coming a) High level overview b) Secure acceptance from everyone that changes need to be made c) Recruit leaders from each area of practice to help with implementation 2. Analyze areas that require significant changes a) Documentation by physicians and staff b) Billing office Transitioning to ICD Create a timeline a) Talk to computer vendor 4. Develop new policies and processes a) Consider all policies / processes linked to diagnosis codes (PQRS, pre-authorizations, chart reviews) b) Create training materials c) Build route slip or other tool(s) for code selection Transitioning to ICD Train physicians and staff a) Emphasize anatomy, physiology, and medical terminology to select ICD-10 code b) New policies and procedures c) Changes to software 6. Test your preparedness in all areas with enough time to fix issues before 10/1/15 Begin Using ICD-10 Codes Practice early, practice often! You are asking people to change habits or patterns This takes time and practice Continue reporting ICD-9 for claims submission Double code a few of claims with ICD-10 codes Compare your answers with each other Use for training and glossary most common codes

30 Begin Using ICD-10 Codes Divide tasks in to workable segments refractive error and cataract codes glaucoma cornea and external eye codes (plastics) retina and diabetes code Injuries and infections Use this time to assess tools available to you Apps, websites etc Use this time to educate staff History taking, documentation, anatomy Now Soon What Next? Review the documentation for your most commonly used diagnosis codes. Improve where necessary! Work with EMR Start coding a small sample of services with ICD-9 and ICD-10 Get staff training Make sure they put it to work! Cataract PCO COAG Blepharochalasis BDR Examples Cataract CC: cataracts, OU, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Refer to cataract surgeon for evaluation Nuclear Sclerotic Cataract What is the appropriate ICD-10 code? Cataract CC: Cataracts, OD, slow decrease VA during past 6 mos, trouble reading, glare worsening Dx: Nuclear sclerotic cataracts OD>OS Tx: Refer to cataract surgeon for evaluation H25.13 NS, Cataract, OU Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: Posterior capsular Opacification (PCO), OS, obscuring vision Tx: Recommend YAG OS After cataract, obscuring vision What is the appropriate ICD-10 code?

31 Secondary Cataract CC: Pseudophake OS, 2 years ago, great difficulty with reading small print Dx: Posterior capsular Opacification (PCO), OS, obscuring vision Tx: Recommend YAG OS H Other 2 nd cat, OS Z96.1 Presence of IOL Chronic Open Angle Glaucoma CC: IOP for Chronic Open Angle Glaucoma OU Dx: Uncontrolled COAG OU ; severe VF loss OD, moderate VF loss OS Test: HVF Primary Open Angle Glaucoma Chronic Simple Glaucoma Severe stage glaucoma What is the appropriate ICD-10 code(s)? Chronic Open Angle Glaucoma CC: IOP for Chronic Open Angle Glaucoma OU Dx: Uncontrolled COAG OU ; severe VF loss OD, moderate VF loss OS Test: HVF 24-2 Blepharochalasis CC: Difficulty with upper field of vision, worsening gradually past 2 yrs Dx: Blepharochalasis, both UL H40.11x3 POAG, Severe stage (no laterality) H40.11x2 POAG, Moderate stage (no laterality) H53.40 Unspecified visual field defects Blepharochalasis What is the appropriate ICD-10 code(s)? Blepharochalasis CC: Difficulty with upper field of vision, worsening gradually past 2 yrs Dx: Blepharochalasis, both UL Strabismus Operative Note You are reviewing the op note for a strabismus case done earlier today. You note it was for exotropia, OD - and that two horizontal muscles of the right eye were operated upon. H02.31 Blepharochalasis, right upper lid H02.34 Blepharochalasis, left upper lid Monocular exotropia What is your ICD-10 code(s)?

32 Strabismus Operative Note You are reviewing the op note for a strabismus case done earlier today. You note it was for exotropia, OD - and that two horizontal muscles of the right eye were operated upon. H Monocular exotropia, right eye Background Diabetic Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes (Note: on oral hypoglycemics only) 2) Mild non-proliferative DR, OU Tx: Letter to PCP/Endocrinologist, Control Blood sugars Recheck 1 yr DM w/ mention of complication, not stated as uncontrolled Mild NPDR What is the appropriate ICD-10 code(s)? Background Diabetic Retinopathy CC: Recently Dx Diabetes (Type II), needs exam Dx: 1) Diabetes (Note: on oral hypoglycemics only) 2) Mild non-proliferative DR, OU Tx: Letter to PCP/Endocrinologist, Control Blood sugars Recheck 1 yr E Type II DM with mild NPDR w/o macular edema