Documentation and Coding for Ophthalmic Diagnostic Tests Financial Disclosure The instructor is a consultant for Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation. Donna McCune, CCS-P, COE Vice President Corcoran Consulting Group Incidental Services Eye Exams Common Ophthalmic Tests Medicare Utilization Patterns (18 - Ophthalmology) Snellen acuity Lensometry Amsler grid Maddox testt Tonometry Ophthalmoscopy Retinoscopy Corneal sensation Confrontation visual field Source: CPT, LMRPs (NY, PA, TN) Ishihara plates Exophthalmometry Keratometry Glare test t Potential Acuity Meter (PAM) Brightness Acuity Test (BAT) Schirmer s tear test Laser interferometry Phacometry CPT Procedure λ CPT Procedure λ 92135 Scanning Laser 30% 92235 Fluorescein 7% 9222x Ext Ophthalmoscopy 15% 92250 Fundus Photo 6% 9208x Perimetry 10% 92020 Gonioscopy 3% --- Biometry (A or OCB) 8% 76514 Pachymetry 2% Frequency is per 100 office visits (%) on Medicare beneficiaries Source: CMS BESS data (2008), 18 Ophthalmology Common Ophthalmic Tests Medicare Utilization Patterns (41 - Optometry) CPT Procedure λ CPT Procedure λ 92135 Scanning Laser 13% 9222x EO 6% 9222x Fundus Photo 10% 92020 Gonioscopy 2% 9208x Perimetry 9% 76514 Pachymetry 1% Plan: Humphrey VF 24-2 MD s Notation: VF Normal Frequency is per 100 office visits (%) on Medicare beneficiaries Source: CMS BESS data (2008), 41 Optometry 92083 365.00 (glaucoma suspect)
Plan: Humphrey VF 24-2 MD s Notation: VF Normal 92083-TC 365.00 (glaucoma suspect) Rationale? Very weak interpretation Chart Documentation Diagnostic Tests Physician s order Why is the test desired? Date performed When was it performed? Technician s initials Who did it? Reliability of the test t Was the test t of any value? Patient cooperation Was the patient at fault? Test findings What are the results of the test? Assessment, diagnosis What do the results mean? Impact on treatment, prognosis What s next? Physician s signature Who is the physician? Visual Field Interpretation October 21, 2009 Mary Smith, COA 1 false positive Good patient t cooperation Arcuate scotoma, OU POAG, shows progression since last visit Add another anti-glaucoma medication \A VA UxààxÜ? `AWA 9208x Visual Field Unilateral or bilateral Indications: glaucoma, ptosis, CNS disorders, retinal abnormalities Perimetry levels: els 1 Limited 1 isopter single stimulus 2 Intermediate 2 isopters suprathreshold 3 Extended 3 isopters threshold Mutually exclusive with other perimetry What s wrong? Plan: Pachymetry MD s Notation: 530 microns OD, 538 microns OS Plan: Pachymetry MD s Notation: 530 microns OD 538 microns OS Rationale? No interpretation 76514 365.00 (glaucoma suspect) 76514-TC 365.00 (glaucoma suspect)
Corneal Pachymetry Chart Documentation Prior surgery Y/N OD OS Technician: Central Corneal Thickness OD mm OS mm Assessment OD Normal Thin Thick OS Normal Thin Thick Interpretation True IOP may be higher than indicated by tonometry True IOP may be lower than indicated by tonometry Tonometry probably sufficiently accurate 76514 Corneal Pachymetry Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral, determination of corneal thickness Indication: glaucoma, corneal edema, corneal ectasia Diagnostic ultrasound Plan: Baseline FP due to FH of glaucoma Plan: Baseline FP due to FH of glaucoma Screening MD s Notation: FP Normal MD s Notation: FP Normal 92250 365.00 (glaucoma suspect) 92250 GY V19.1 (FH other eye disorders) 92250 Fundus Photography Bilateral Indication: serious posterior segment disease Repeated for progression of disease or new findings NCCI: Bundled with ICG (92240) Assessment: VA worsening; possible progression of AMD Plan: Perform FA / FP / OCT OU for wet AMD 92235-50, 92250, 92135-50 362.52 (wet AMD)
Assessment: VA worsening; possible progression of AMD Plan: Perform FA / FP / OCT OU for wet AMD Mutually exclusive 92235-50, 92135-50 362.52 (wet AMD) 92135 SCODI Scanning computerized ophthalmic diagnostic imaging, posterior segment, (e.g., scanning laser) with interpretation and report, unilateral Added to CPT in 1999; revised 2008 Indication: glaucoma, some retinal disease Repeated periodically NCCI: mutually exclusive with FP (92250) 7,000,000 6,000,000 5,000,000 4,000,000 Medicare Utilization 92135 Utilization 3,000,000 2,000,000 1,000,000 0 1997 1999 2001 2003 2005 2007 2009 MD OD Medicare s Coverage Policy For Glaucoma 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 Source: CMS BESS data (1998 2008), 18 Ophthalmology, 41 - Optometry 1 In this context, tests means SCODI or perimetry Medicare s Coverage Policy For Retinal Disorders 92235 Fluorescein Angiography "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, ation 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." Unilateral Indication: serious posterior segment disease Repeated for progression of disease or new findings Numerous NCCI bundles LCD National Gov t Services 1/1/09
Assessment: Narrow angles OU MD s Notation: Gonioscopy OU Grade II angles OU Assessment: Narrow angles OU MD s Notation: Gonioscopy OU Grade II angles OU 92020 RT 92020 LT 365.20 (primary angle closure glaucoma) Bilateral test 92020 365.20 (primary angle closure glaucoma) 92020 Gonioscopy 92020 Gonioscopy Bilateral Indication: glaucoma, neovascularization, synechiae NCCI: bundled with external photography (92285) CLOSED SL 0-1 ATM 1 TM 2 SS 3 CB 4 DX: Narrow Angle Glaucoma, OU Source: Numerical system from Scheie Separate Procedure Gonioscopy Unilateral Services Office Visit or Consult 366.16 Nuclear cataract Gonioscopy 365.23 Chronic angle closure 92070 92135 9222x 92235 92240 92287 Therapeutic contact lens Scanning computerized ophthalmic diagnostic imaging Extended ophthalmoscopy Fluorescein angiography ICG angiography Anterior segment fluorescein angiography Source: Medicare Physician Fee Schedule
Assessment: Diabetes w / out signs of diabetic retinopathy MD s Notation: Extended Ophthalmoscopy OU WNL Assessment: Diabetes w / out signs of diabetic retinopathy MD s Notation: Extended Ophthalmoscopy OU WNL Incidental 92225 RT 92225 LT 250.00 (Diabetes w/out complications) Office visit (9xxxx) 250.00 (Diabetes w/out complications) 92225, 92226 Extended Ophthalmoscopy 92225, 92226 Extended Ophthalmoscopy Unilateral 92225 Initial 92226 Subsequent (I.e., for the same condition) Indication: serious posterior segment disease Requires retinal drawing Characteristics: large, scaled, colored, detailed, labeled Repeated for progression of disease or new findings No NCCI bundles Retinal Detachment Hard exudates Assessment: visually significant cataracts OU; VA worsening OU, ADL concerns, particularly driving; patient desires to proceed with cataract surgery OD with conventional IOL Plan: Perform corneal topography, SCODI, endothelial cell count, A-scan biometry, and IOL Master 92025, 92286, 76519, 92136 366.16 (nuclear sclerotic cataract) Assessment: visually significant cataracts OU; VA worsening OU, ADL concerns, particularly driving; patient desires to proceed with cataract surgery OD with conventional IOL Noncovered Plan: Perform corneal topography, SCODI, ABN endothelial cell count, A-scan biometry, and IOL Master Incidental 76519 366.16 (nuclear sclerotic cataract)
Beneficiary Liability 76519 A-scan Biometry 1... a comprehensive eye examination... and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, t a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B- scan may be used. BILATERAL MEASUREMENT BOTH EYES 60% 40% -TC -26 UNILATERAL INTERPRETATION PER EYE Source: MCM 35-44 Coverage Issues Manual (CMS-Pub. 6) 1 Source: 1994 LMRPs 76519 A-scan Biometry 92286 Endothelial Cell Photography Method 1 First cataract 76519 RT Second cataract 76519 26LT Method 2 First cataract 76519 TC 76519 2650 Second cataract Nothing billed Special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count Bilateral Indication: corneal disease or abnormalities Photographic documentation in medical record Note: 76519-RT = 76519-TC + 76519-26RT Medicare s Coverage Policy Endothelial Cell Photography 1 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 pre-surgical comprehensive eye examination or combination brief/intermediate examination provided prior to cataract surgery, and not in addition to it. 92136 Optical Coherence Biometry Bilateral technical component Unilateral 1 professional component Added to CPT in 2002 Indication: cataract, lens exchange NCCI: Mutually exclusive with A-scan biometry 1 NCD 80.8 1 CMS PM Transmittal 105 (February 20, 2004) Effective Retroactive to January 1, 2004
92025 Corneal Topography Computerized corneal topography, unilateral or bilateral, with interpretation and report Advance Beneficiary Notice of Noncoverage (ABN) Form effective 1/1/03, revised 2008 effective 3/1/08, required on or after 3/1/09 Mandated by HIPAA Notice that Medicare will probably deny reimbursement Document reason why item is not covered Give signed copy of ABN to patient (recommended) Collect full fee from patient Source: CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) Option 1. I want the listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment I can appeal to Medicare Option 2. I want the listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal to Medicare Option 3. I don t want the listed above. I understand with this choice I am not responsible for payment I cannot appeal to Medicare Plan: RTO when blood sugar stabilizes for manifest refraction MD s Notation: Unreliable refraction Patient 92015 250.02 (uncontrolled diabetes) Plan: RTO when blood sugar stabilizes for manifest refraction MD s Notation: Unreliable refraction Incidental Eye exam (9xxxx) 250.02 (uncontrolled diabetes) 92015 Refraction Determination of refractive state Special ophthalmological services describes services in which a special evaluation of part of the visual system is made, which goes beyond the services included under general ophthalmological services may be reported in addition to the general ophthalmological services or E/M services. Includes prescription of lens(es) when required
FTC Prescription Release Rule require an eye care practitioner (an optometrist or ophthalmologist) to provide a patient, immediately after completion of an eye examination, with a free copy of his or her eyeglass prescription. The [Ophthalmic Practice] Rules also prohibit an eye care practitioner from conditioning the availability of an eye examination on a requirement that the patient agree to purchase ophthalmic goods from the practitioner. The Rules further prohibit an eye care practitioner from making certain disclaimers and waivers of liability. Supervision General supervision Physician reviews notes Direct supervision Physician immediately available Personal supervision Physician in the room Source: Source: Advertising of Ophthalmic Goods and Services, Statement of Basis and Purpose and Final Trade Regulation Rule, 43 FR 23992, 23998 (June 2, 1978) General Supervision Perimetry Fundus photography External ocular photography Scanning computerized ophthalmic diagnostic imaging Orthoptics Et Extended ddcolor vision ii testingti Dark adaptation exam EKG Visual evoked potential (VEP) done by certified tech A-scan biometry Specular endothelial microscopy and cell count Pachymetry Source: PM B-01-28 and PM 1725 effective 7/1/01 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: PM AB-02-112 effective 7/31/02 Personal Supervision Oculoelectromyography (OEM) Incident to Services Tech Exams Incident to a physician s professional services means that the services or supplies are furnished as an integral although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness.... limited to situations in which there is direct physician supervision of auxiliary personnel. Source: PM B-01-28 effective 7/1/01 Source: MBPM, Chapter 15, 60.1
Testing During Postop Period Services not included in the global surgery package: Diagnostic tests and procedures, including diagnostic radiological procedures Modifiers TC technical component 26 professional component RTright eye LT left eye 50 both eyes GA patient signed Advance Beneficiary Notice Source: MCPM, Chapter 12, 40.1B Billing Procedures Technical and Professional Components Global Single service Billed at conclusion Completed test Results in chart Interpretation documented Segregated Two services Billed separately TC technical component 26 professional component Examples Purchased test Hospital-based test Performed on different days Date of Service Diagnostic Tests Interpretation and Technical Component The appropriate Date of Service (DOS) for the professional component is the actual calendar date that the interpretation was performed. For example, if the test or technical component was performed on April 30th and the interpretation was read on May 2nd, the actual DOS for the performance of the test is April 30th and the actual DOS for the interpretation or read of the test is May 2nd. Source: CMS CR 6375 MCPM, Chapter 26, 10.6.3 (Implement 1/4/10, effective 7/1/10 POSTPONED for now)