Evaluation and Management Codes Documentation Guidelines...1 Medicare...1 Overview of Medicare...1 Medicare Covered Services and Materials...1 Non-Covered Services and Materials...1 Medicaid...2 Limitations on Medicaid Services...2 Vocational Rehabilitation Program...2 Vision Service Plan (VSP)...3 I.U. Safety...3 Spectera...3 Risk Management...3 Student Bursar Accounts...3 Children s Glasses Program...3 Vision USA Program...4 Disabled American Veterans (DAV) (IECC Only)...4 Homeless Initiative Program (HIP) (IECC Only)...4 Gennesaret Free Clinic (GFC) (IECC Only)...4 Other Third Party Insurers...4 Documentation and Third Party Reimbursement...4 Handwritten Notes...5 Timeliness...5 Specificity...5 Date and Signature...5 Third Party Fee Collection...6 Examination Fees...6 Ophthalmic Materials...6 i
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The Indiana University School of Optometry Eye Care Centers participate in a wide variety of third party insurer programs including government programs like Medicare and Medicaid; commercial plans like Vision Service Plan; and Indiana University programs such as I.U. Safety. This section provides a brief summary description of the majority of third party plans billed by the clinics for the services and materials we provide. Evaluation and Management Codes Documentation Guidelines All students and providers associated with the IU School of Optometry are expected to be familiar with and exhibit the correct use of CPT (procedural) and ICD-9 (diagnostic) codes. It should be noted that certain procedures, such as foreign body removal, will need a modifier. The modifier tells the insurance company that the eye had to be looked at first before removing the foreign body. This way, the procedure (foreign body removal) AND the examination that determined the need for the procedure will be reimbursed Medicare Overview of Medicare Medicare is the federal health insurance program which provides medical coverage for people 65 and older, for certain disabled people, and for certain people with end-stage renal disease. Medicare is managed by the Centers for Medicare and Medicaid Services (CMS), which is a branch of the Department of Health and Human Services (HHS). Medicare Covered Services and Materials The following are routinely covered: Medically indicated examinations and treatment, including annual dilated diabetic eye examinations. A medically indicated examination results from an entering patient symptom or complaint which results in a medical (non-refractive) ICD-9 diagnosis. One complete pair of glasses or contact lenses after each cataract surgery. After paying an annual deductible, Medicare will reimburse the patient for 80% of the cost of a standard frame. The patient pays the remaining 20% of the cost. Additionally, the patient must pay the difference for a more expensive upgraded frame. Most lens addons are not covered and sunglasses are never covered. Glaucoma Screening Medicare covers glaucoma screening, once every 12 months for people at high risk for glaucoma. This includes people with diabetes, a family history of glaucoma, or African- Americans who are age 50 or older. The screening must be done or supervised by an eye doctor who is legally allowed to perform this service in your state. Treatment of Macular Degeneration Medicare covers ocular photodynamic therapy treatment for "wet" age related macular degeneration with predominantly classic lesions. Non-Covered Services and Materials The following are not routinely covered: Routine examinations (all examinations and services must be medically necessary ). 1
Procedures performed to determine the refractive state of the eyes (e.g., refractions). Eyeglasses and contact lenses except after cataract surgery. Services not within the scope of state licensing laws. Please note that you must inform each patient prior to performing a non-covered service or procedure. The patient is responsible for the total cost of the service or procedure. Medicaid The Indiana Family and Social Services Administration (FSSA) is the agency in charge of the Indiana Medicaid System. The Medicaid system is run by the State of Indiana, but funded jointly by the state and federal governments. Limitations on Medicaid Services 1. Eyeglasses Medicaid authorizes coverage of one (1) pair of eyeglasses twelve (12) months after the last pair of glasses for children age 18 and under and one (1) pair twenty-four (24) months after the last pair of glasses for adults age 19 and up. The patient must exhibit at least 0.75D/15º of change in one eye if between the ages of 6 and 42 years and at least 0.50D/15º of change if over the age of 42. If these conditions are not met, the prescription change is not considered medically necessary and Medicaid will not pay for new glasses. Borderline situations should be evaluated individually. Additionally, the following conditions apply: Frames - frames must be chosen from a designated Medicaid frame inventory. Lenses - only plastic lenses are covered. Other options will be paid for if deemed medically necessary. A Medicaid-sponsored patient may request options outside of the limitations listed above. These options are considered add-ons to the approved pair of glasses, and must be paid for in full by the patient at the time the order is placed. Broken glasses may be replaced with completion of a signed waiver. Replacement of glasses under these conditions effectively determines a new start of the 12 or 24 month time period during which beneficiaries cannot get glasses. 2. Complete Routine Eye/Refractive Examination Medicaid will allow one (1) complete routine eye/refractive examination every twelve (12) months for children age 18 and under and one (1) every twenty-four (24) months for adults age 19 and up. 3. Contact Lenses Medicaid will only pay for contact lenses in cases of medical necessity, such as aphakia or keratoconus. Vocational Rehabilitation Program This government program is managed by the Indiana Family and Social Services Administration. Patients are referred by Vocational Rehabilitation counselors who authorize a primary care or low vision examination. If materials are required, they must be requested on a blue Medical Report form that is to be completed and returned to the Vocational Rehabilitation counselor. Materials cannot be 2
ordered or services rendered until a written authorization is received from the Vocational Rehabilitation counselor. Vision Service Plan (VSP) This insurance is purchased by individual employers for their employees. It is usually sold to other health insurance plans as a rider that an employer and employee can purchase at an additional cost. Benefit coverage varies from employer to employer depending on the benefit plan(s) purchased. However, typical coverage includes a comprehensive exam and a discount on ophthalmic materials. I.U. Safety The IU School of Optometry clinics provide prescription safety eyewear for employees of Indiana University whose jobs pose identified eye injury hazards. IU employees may use either the School or other providers for their eye examinations. However, prescription lenses and frames must be issued by either CECC or AECC. A current copy of the Indiana University Safety Eyewear Policy is included in the appendices. Spectera Spectera is a vision insurance plan typically separate from any major medical plan directly to employers. The plan provides coverage for routine eye care and materials. To receive full benefits for eye wear materials, Spectera members must select from a plan-approved inventory of frames and contact lenses (see the Dispensary Manager or Contact Lens Technician prior to selection). Benefits vary from employer to employer depending on the richness of the benefit plan(s) purchased and made available to their employees. Please see the Front Desk Staff for questions concerning benefits and eligibility. Risk Management Risk Management is a department on the IU Bloomington campus which processes Worker s Compensation claims for Indiana University employees injured on the job. In addition, the School of Optometry provides the vision care for the IU athletes. Eye care services performed by our clinics are billed to and paid by the Risk Management department. Student Bursar Accounts Enrolled IU students with a valid IU student ID may choose to charge their bursar account for services/materials they receive at any of the IUSO eye care centers. They must provide their ID so a copy can be made for their patient file. They must also complete an authorization to bill form at the payments desk which will also be kept in their patient record. Once a charge is processed to the Bursar s office, all payments and/or credits will be handled through the Bursar s office. Children s Glasses Program The Children s Glasses Program allows parents to purchase a complete warranted frame with lenses, with backing provided by Bell Optical Lab. The program has the following guidelines: The warranty is for a period of 18 months. It covers breakage of the frame and/or lenses only; scratching of lenses only is not included. All broken parts must be returned for the warranty to be valid. 3
The package includes single vision polycarbonate lenses and a complete frame from a designated frame inventory. Many options, such as tints and scratch-resistant coatings will result in additional charges. Bifocal lenses are also available through the Children s Program for an additional fee. One temple will be engraved with the child s name or telephone number. Polycarbonate lenses are recommended for all children due to their impact resistance, their built-in ultraviolet (UV) protection, and their scratch-resistant coating. Vision USA Program This program, for low-income working patients without eye care insurance, is sponsored by the AOA and administered on a state level. Qualified patients receive a donated eye examination. Donated frames and free or reduced rate lenses (with no add-ons allowed) may be available. Contact the Vision USA State Coordinator for details. Refer to the AOA website (www.aoanet.org) for further information, a list of state coordinators, and an application. Disabled American Veterans (DAV) (IECC Only) A special grant fund is available to IECC to provide eye/vision care services for homeless veterans referred to the clinic by the local chapter of the DAV. Homeless Initiative Program (HIP) (IECC Only) Homeless patients who are referred to the IECC by the Homeless Initiative Program Director are given a free eye examination. The examination is a donated service; HIP is billed for the frame and basic lenses. No add-ons are allowed. We do not require referral forms for the patients seen under the program. Gennesaret Free Clinic (GFC) (IECC Only) These patients are referred to the IECC by the Gennesaret Free Clinic staff members. Examination costs and spectacle fees are covered by GFC grant funds. Other Third Party Insurers The third party insurers listed above cover the majority of our clinic patients. However, many others exist. If you examine a patient with a non-listed third party plan please ask the staff about their benefit coverage. Documentation and Third Party Reimbursement Medical records are viewed by payers as the source of information regarding patient encounters. Therefore, documentation in the medical record is necessary to substantiate the performance of a billed service. The primary purpose of medical records is to communicate clinical information to all staff involved in the patient s care. The documentation serves as a receipt of services rendered. The medical record provides written proof of services if a payer or patient has a question regarding a claim or services rendered. When a service is questioned, the medical record must substantiate all services performed and justify those services. When services billed cannot be verified, the clinic risks not getting paid or 4
having to refund payment (either to the patient or the payer) for those services. In addition, the medical record is a legal document that protects both the clinic and the patient from a liability standpoint. Handwritten Notes Illegibly written notes, shorthand, or abbreviations that only you can decipher will not meet most third party documentation requirements. All handwritten record entries and notes must be legible. When making corrections, use a single, straight line through the error and note the correction above or to the side. Covering up an error with whiteout or blackening is prohibited; it may be construed as an attempt to hide an error rather than a correction. Always date, sign, and document the reason for the corrections. Entries by staff members should be countersigned or initialed and dated by the faculty consultant. Timeliness When the documentation of an encounter is delayed, you must rely on your memory to reconstruct the encounter. This often results in incomplete and erroneous medical records. Please complete your documentation before you leave the clinic at the end of each day. Specificity All billed services and/or materials must be adequately documented in the patient s chart. The encounter should be recorded exactly as it happened. Information should be listed in clear, concise terms that reflect CPT and ICD-9 terminology. You should familiarize yourself with frequently used CPT codes. Specific attention should be placed on the different descriptors within a family of codes which distinguishes one code from another. This will permit you to include crucial information in the source documentation to support the code selected. The documentation should be specific enough to validate the specific CPT code selected. All coded information must appear in the medical record. Checking a diagnosis or procedure on the Service Summary does not take the place of documentation in the medical record, as the Service Summary is not part of the medical record. In order to determine if contractual obligation to enrollees is met (and not exceeded), payers will validate documentation of services to ensure consistency with insurance coverage provided. To accomplish this, the accuracy of services reported is often reviewed. Inability to correlate documentation with procedural and/or diagnostic coding may result in third party denial of services or cancellation of a managed care contract. Date and Signature All entries should be dated and signed. The date of service shown in the medical record should be the same as the date of service billed. If these dates do not correspond, the payer may deny the claim based on lack of supporting documentation. This error commonly occurs when there is a delay between the provision and the documentation of the service. Occasionally, a practice may use a stamp which indicates that a medical record was dictated but not read by the optometrist. Faculty consultants must be personally involved in the supervision of services rendered. Since most payers consider signatures as an attestation to the accuracy of the documentation, use of a stamp may violate your obligation to meet this requirement. Payers require that all entries be signed or initialed in such a way that the provider of the service is clearly noted. Any other method is considered unacceptable and may expose the clinic to potential risk of liability or other legal difficulties. 5
Third Party Fee Collection Examination Fees All examination/fitting/service fees, including patient co-payments and non-covered fees, must be collected in full at the time of the visit. Ophthalmic Materials Each patient is required to pay a fifty percent (50%) deposit prior to ordering any ophthalmic materials, including frames, lenses, completed eyeglasses, contact lenses, and low vision devices. The materials will be dispensed to the patient upon receipt of the balance due on these materials. Exceptions to this rule may only be made by authorization of the Clinic Director or the Clinic Administrator. 6