BSM Connection elearning Course

BSM Connection elearning Course Common Documentation and Coding Errors: Office Visits and Diagnostic Tests 2008, BSM Consulting All Rights Reserved.

Table of Contents OVERVIEW...1 PART I: OFFICE VISITS...1 PART II: DIAGNOSTIC TESTS...4 CONCLUSION...9 COURSE EXAMINATION...10 2008, BSM Consulting

OVERVIEW If your practice is busy and profitable, that is a good thing. However, even a successful practice can leave itself vulnerable to a number of common documentation and coding errors, especially in two critical areas: office visits and diagnostic tests. This course is written with two goals in mind: 1) to make practice staff aware of the most widespread documentation and coding errors in these two areas, and 2) to offer insights and hints related to successfully meeting these challenges in an efficient and professional manner. PART I: OFFICE VISITS Vision care providers struggle with charting and coding for office visits, making frequent and sometimes costly errors. Most errors require minimal effort to fix. Not correcting these errors may result in sizeable overpayments in a post payment review. This article focuses on common documentation and coding errors associated with office visits and provides some helpful hints to fix them. Chart Template Many physicians continue to utilize ruled binder paper or a blank sheet of paper in the patient s medical record to document visits, believing templates are too confining or create waste and bulky charts. Without a template, physicians often summarize findings. For example, the discrete elements of the slit lamp exam or fundus exam are not detailed in the chart notes. Frequently, documentation includes the pertinent positives and omission of normal findings. Not infrequently, there is no mention of other essential elements of an eye exam such as gross visual fields and basic sensorimotor exam. Chart notes are short. Sometimes, more than one office visit appears on a single sheet of paper. Helpful Hint: While chart forms are not required, they are helpful as a checklist to ensure that medical records contain essential notations. Flawed Chart Form Requirements for documenting specific exam elements exist whether using eye codes (920xx) or evaluation and management codes (992xx). If an element (e.g., external/adnexa) is inadvertently left off a chart form, the ability to code some levels of service is compromised. The CPT definition for the ophthalmology codes includes documentation of the adnexa for both the comprehensive and intermediate eye exam codes (920xx). An inadvertent error such as this could be very costly to the practice. Helpful Hint: When using chart forms, make sure all required elements are included. Completing the Chart Note Chart forms provide a reminder to physicians about the various elements of an office visit. However, its effortlessness can work against you if its completion is sloppy, inaccurate, or unnecessary. The level of service selected should reflect the patient s complaint, number of exam elements documented, and often the gravity of the presenting condition. Chart notes that contain careless notations (such as a straight line through a series of boxes on a chart form labeled normal ) may not be accurate or credible. This is especially true when the element is marked normal and the assessment indicates an abnormality. Some chart notes, including notations that are not useful or necessary in relation to the presenting problem or condition, may lead to upcoding. The converse is also true: incomplete chart notes create a need to downcode the encounter that otherwise merited a higher level of service. Helpful Hint: Missing entries and carelessly documented entries are very obvious when chart forms are used. Select a level of service commensurate with the documentation in the medical record. 2008, BSM Consulting 1

Illegibility Careless entries are problematic, but entries that cannot be deciphered due to poor handwriting pose a serious concern about the adequacy of the records to support claims for reimbursement. In group practices, providers handwriting quality varies. If one provider cannot read the notes of another provider, continuity of care is jeopardized; in addition, staff members struggle to handle phone calls about prescriptions. Auditors become frustrated when notes cannot be read and may consider the note invalid or useless. Hold staff members accountable for making legible entries in the patient s medical record. Many practices utilize scribes to help make the records more legible, complete, and useful. Helpful Hint: Illegible records are very nearly worthless. Entries must be understandable to other doctors and staff members, not just the original physician. EMR Solution Some practices institute electronic medical records (EMR), because they believe that the ability to document very detailed visits improves compliance. Features such as copy forward and computerized recommendations for code selection seem attractive. Unfortunately, these reasons provide a false sense of security and will likely work against you in a post payment review. Consider the following case study. A large practice instituted a new electronic medical record system that resulted in extraordinarily detailed chart documentation. Every office visit included a comprehensive history and comprehensive exam. In most cases, an established patient office visit incorporated entries from the prior encounter verbatim the copy forward feature was a favorite of the users. The EMR system made recommendations for selecting an evaluation and management (E/M) code based on the number of fields that were completed by the user. Most of the time, a level 4 or 5 E/M code was recommended. Eye codes were never selected. Shortly after a perfunctory post payment review, the practice was advised of extremely serious allegations concerning the medical records. Federal and state officials began a criminal investigation. The notes in the EMR system were alleged to be fake since they were repetitive from one encounter to the next, overly verbose, and not believable. Investigators said, These charts are too good they can t be real. The practice mounted a vigorous legal defense which was tedious, time consuming, and expensive. Individual patients were asked to testify on behalf of the practice about their office visits. During the period of time that the practice was fighting with government officials, they were placed on prepayment review, which mandated that all claims be submitted with a copy of the medical record before any reimbursement could be made. Cash flow was seriously disrupted. Helpful Hint: EMR is not a panacea for chart documentation. Overzealous chart notes are not credible. When credibility is compromised, it s hard to support claims for reimbursement. Consultation Requests In January 2006, the Centers for Medicare and Medicaid Services (CMS) provided updated information associated with documenting consultative services. Many commercial payers adopted the same approach. The revised Consultation Request section of the CMS guidelines states, The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP (non-physician practitioner). A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient s medical record. The need to document a request for consult has never been in doubt, but the method of documentation has changed. 2008, BSM Consulting 2

Written documentation of the request for consultation is easier to ascertain with a shared medical record (i.e., group practice, nursing facility, hospital). The request for consult is indicated in the requesting physician s plan and is self-evident to the consulting physician. From the consulting physician s perspective, the nature of the request is less obvious when the medical record is not shared. (Does the requesting physician send his/her chart notes to the consultant?) Although not required, consider using a request for consultation form. A copy of the form in both providers records substantiates the request for consultation and medical necessity. Helpful Hint: Require referring physicians to send a consult request form to eliminate the uncertainty of a consult vs. transfer of care and to satisfy the written request requirement. Coding Error Vision care providers prefer eye codes due to their ease of documentation and utilize them for approximately 70% of all encounters. Some reviewers use the precise definitions contained in CPT as the basis for severe criticism of claims for office visits where eye codes (920xx) are submitted. Specifically, if the chart note does not contain required elements for intermediate or comprehensive eye exams, then refunds may be necessary. For example, 92004/92014 requires the Initiation of diagnostic and treatment program. Also, 92002/92012 requires an evaluation of a new or existing condition complicated with a new diagnostic or management problem. The CPT definitions cite specific required exam elements and may be referenced in the course of a chart review. For example, comprehensive exams (920x4) require examination and documentation of gross visual fields and a basic sensorimotor exam. Helpful Hint: Become familiar with the language in CPT and not just the few words that accompany the code. The definitions in the preamble are also important. Coding Simplicity Few would argue that understanding the E/M guidelines is challenging and complex. The E/M codes require copious chart notes with intricate rules for history documentation and exam requirements. Keeping it simple by using eye codes exclusively is tempting. Unfortunately, the eye codes do not cover every type of service provided. Extremely simple cases and emergent cases cannot be captured adequately with an eye code. Helpful Hint: Do not use either E/M or eye codes exclusively. A mixture of E/M and eye codes works best. Vision Exams Many patients present with dual insurance coverage. A medical plan covers a medical diagnosis and a vision plan covers a refractive condition. Confusion exists as to which plan should be primary at the time of the patient encounter. The answer to this question is straightforward but often ignored. Coverage depends on the reason for the visit from the patient s perspective. Exams for medical care, evaluation of a complaint or to follow an existing condition should be billed to the medical plan. Alternately, exams to check vision, screen for disease, or update eyeglasses or contact lenses should be billed to the patient or the patient s vision plan. A common scenario is the patient who presents for a routine vision exam and pathology is found. Which plan is primary? The chief complaint should comport with the primary diagnosis and determine coverage. In this case, the chart may read, Here for routine eye exam and new glasses, with a corresponding diagnosis of refractive error: myopia, hyperopia, astigmatism, or presbyopia. The incidental finding of pathology should be addressed on a return visit (unless urgent or emergent). Subsequent exams to monitor or treat the pathology can be billed to Medicare or the medical plan. 2008, BSM Consulting 3

Helpful Hint: Do not bill medical plans for routine vision care and vice versa. Utilize the chief complaint to determine which plan is primary for the visit. Simplified Process First and foremost, a physician wants to provide quality care to patients. Even so, chart notes aren t always up to speed and claims for reimbursement may be in error, giving Medicare and third-party payers ample reason to be suspicious. Many aspects of documentation and coding can be simplified by the helpful hints described above. Although challenging, getting it right does not need to be difficult. PART II: DIAGNOSTIC TESTS More than half of all eye exams and consultations on Medicare beneficiaries are accompanied by an ophthalmic test such as refraction, gonioscopy or A-scan biometry. Overall, the single most frequent ophthalmic test, without regard to the source of payment, is refraction (92015). The most frequently reimbursed test performed by ophthalmologists is scanning computerized ophthalmic diagnostic imaging (SCODI, 92135), which increased 28% within the Medicare program from 2005 to 2006. It is noteworthy that optometrists also logged large increases in the number of most common diagnostic tests performed on Medicare beneficiaries. Increased utilization often spurs increased attention by third-party payers. Are you familiar with the regulatory issues surrounding diagnostic tests? Are you documenting and coding tests appropriately? This article explores some of the regulatory issues, documentation requirements, and coding of diagnostic tests and provides helpful hints to assist with compliance. Supervision Under Medicare rules, diagnostic tests must be performed under the supervision of an individual meeting the definition of a physician to be considered reasonable and necessary and, therefore, covered under Medicare. (PM B-01-28). Medicare has established three different levels of physician supervision of technicians commensurate with the risk to the patient and/or the skills needed to obtain useful results. 1. General supervision means the procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. 2. Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. 3. Personal supervision means a physician must be in attendance in the room during the performance of the procedure. Prior to July 1, 2001, no ophthalmic diagnostic test was classified in the general supervision category. Since then, Medicare has liberalized the supervision requirements for many ophthalmic tests. 2008, BSM Consulting 4

According to Medicare, the following tests require general supervision: CODE DESCRIPTION 92065 Orthoptics 9208x Visual Fields 92135 SCODI 92250 Fundus Photography 92270 Electro-Oculography 92275 Electroretinography 92283 Extended Color Vision Testing 92284 Dark Adaptation Exam 92285 External Ocular Photography 92286 Endothelial Cell Count 76514 Corneal Pachymetry, Ultrasound 76516 A-Scan Biometry 76519 A-Scan Biometry with IOL Calculation 76529 Ultrasound Foreign Body Localization According to Medicare, the following tests require direct supervision: CODE DESCRIPTION 92235 Fluorescein Angiography 92240 ICG Angiography 95930 Visual Evoked Potential 76510 A- and B-Scan, Diagnostic 76511 A-Scan, Diagnostic 76512 Contact B-Scan 76513 Immersion B-Scan According to Medicare, the following test requires personal supervision: CODE DESCRIPTION 92265 Oculoelectromyography Other special ophthalmological services not specifically listed above must be performed by the physician (e.g., gonioscopy, extended ophthalmoscopy). They are not assigned separate technical components (TC) or professional components (26) in the Medicare Physician Fee Schedule. Helpful Hint: Understand the definitions for supervision levels and know which tests fit into each category. Take advantage of times when physicians are not in the office to perform tests under general supervision, thus maximizing technician effectiveness. 2008, BSM Consulting 5

Ordering Tests All diagnostic tests that are not personally performed by the physician require the physician s order. It is usually noted as part of the plan in the medical record. It may be a notation as simple as VF today, FA OD next visit, or as complex as ordering extensive blood chemistry tests at the hospital. Medicare and other payers expect that the physician ordering the test will use the test (42 CFR 410.32) and has the capability to do so. The regulation states, Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. This means that he or she is managing the disease for which the test was ordered and that treating the disease is within his or her scope of practice. Standing orders may improve office efficiency, but they usually create problems with reimbursement. Within Medicare s regulations, there are numerous statements precluding reimbursement for so-called PRN or standing orders, because they are routine screenings and non-covered services. To avoid this difficulty, physicians should examine the patient first and then determine which tests (if any) are necessary. Helpful Hint: Note test orders as part of the patient s permanent medical record, documenting them in the plan; examine patients prior to ordering tests. Interpretations The phrase with interpretation and report is found in the description of many ophthalmic diagnostic tests. This does not mean that a lengthy or dictated report is required. It does mean that the physician must look at the results of the test, make an interpretation, and place a notation in the patient s medical record within a short time of the test results being available. At a minimum, interpretation of a diagnostic test includes: an order for the test with medical rationale the date of the test the reliability of the test the test findings a diagnosis (if possible) the impact on treatment and prognosis, if any the signature of the physician An interpretation can be written on a separate page in the medical record, as a discrete entry together with other evaluation and management services, or in the blank space on the printout of the test results (e.g., visual fields). Helpful Hint: Diagnostic test claims for reimbursement are incomplete without documentation of the interpretation in the medical record. Review and document the interpretation in a timely fashion. Bilateral or Unilateral Test The CPT book does not usually provide a clear distinction between diagnostic tests considered bilateral (file claims once for both eyes) and unilateral (file claims per eye). Some diagnostic tests are defined by Medicare; other third party payers often disagree with these rules. 2008, BSM Consulting 6

Medicare defines the following tests as bilateral. Reimbursement is the same whether one eye or both eyes are tested. No additional reimbursement is made if they are billed with modifier 50 or RT/LT. 76514 Pachymetry 92020 Gonioscopy 92025 Corneal topography 92060 Sensorimotor examination 92065 Orthoptic and/or pleoptic training 92081 Visual field, limited 92082 Visual field, intermediate 92083 Visual field, extended 92100 Serial tonometry 92120 Tonography 92130 Tonography with water provocation 92136 Optical coherence biometry 92140 Provocative test for glaucoma 92250 Fundus photography 92260 Ophthalmodynamometry 92265 Oculoelectromyography 92270 Electro-oculography 92275 Electroretinography 92283 Extended color vision exam 92284 Dark adaptation exam 92285 External ocular photography 92286 Endothelial cell count w/ photograph 92287 Anterior segment photograph w/fa 95930 Visual evoked potential Some special ophthalmological services are defined as unilateral in CPT, or Medicare categorizes them as such. It is important to note that Medicare believes these procedures are commonly performed on just one eye as disease may only exist in one. 92070 Fitting of therapeutic contact lens 92135 Scanning computerized ophthalmic diagnostic imaging 92225 Extended ophthalmoscopy, initial 92226 Extended ophthalmoscopy, subsequent 92230 Fluorescein angioscopy 92235 Fluorescein angiography 92240 ICG Angiography When these tests are performed on both eyes at the same time, reimbursement is 200% of the allowable instead of 150% that is customary for surgical procedures. Some Medicare Administrative Contractors (MACs) prefer modifier 50 appended to the CPT code while others prefer a two-line entry with RT and LT. 2008, BSM Consulting 7

Helpful Hint: Recognize which tests are reimbursed per eye and which are considered bilateral. Be mindful of filing unilateral tests when the disease presents in only one eye. Covered Indications Third party payers cover diagnostic tests considered medically necessary. Medicare defines medical necessity as a service that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. If the patient presents with a complaint that leads the physician to order and perform this test or as an adjunct to management and treatment of a known disease, the service may be considered covered. Some MACs publish local coverage decisions (LCDs) describing approved indications (ICD-9 codes) for specific diagnostic tests. For example, SCODI policies include a detailed list of glaucoma diagnoses and some posterior segment diseases. Policies vary among MACs. It is important to check your local policies for a comprehensive list of covered diagnoses. The selection of a diagnosis code for ophthalmic tests can be challenging. In September 2001, CMS issued a clarification on the use of ICD-9 diagnosis codes with diagnostic tests (PM B-01-61). This clarification specifies that a confirmed diagnosis should be coded on the claim whenever possible. The diagnosis code chosen should be to the highest level of specificity. When a definitive diagnosis is not made, signs and symptoms may be used on the claim if the LCD includes symptoms as approved diagnosis codes. Above all, do not use probable, suspected, questionable, or rule out diagnosis on a claim. If tests are performed as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then they are not covered even if disease is identified. This does not preclude you from performing and being paid for these tests. However, the patient would be responsible for payment as long as the appropriate financial waiver has been presented and signed by the patient in advance of testing. An Advance Beneficiary Notice of Denial (ABN) informs the patient that Medicare coverage is uncertain. For example, an ABN is appropriate when a disease is suspected but not found or an indication is not covered by the local Medicare policy. Helpful Hint: Review LCDs for approved indications for diagnostic tests. Utilize ABN when coverage is uncertain. Frequency How often a test may be reimbursed is a frequent question. In general, diagnostic tests are reimbursed when medically indicated. Repeated testing usually occurs when there is a change in the condition or progression of disease. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from payers. Some LCDs publish utilization guidelines as a reference. The guidance typically applies to the average patient requiring this test. Not all patients are typical, so the decision to repeat a test is the physician s and not the payers. If a claim is denied due to frequency limitations, a successful appeal depends on the documentation supporting the need to repeat the test. For example, the following guidance exists in many LCDs for SCODI when performed for glaucoma patients. In this context, tests means SCODI or perimetry: Preglaucoma or mild damage o Early detection of glaucoma o One test per year Moderate damage o One or two tests per year 1 2008, BSM Consulting 8

Advanced damage o Rare indication for SCODI In addition to LCDs, the American Academy of Ophthalmology publishes Preferred Practice Patterns providing guidance on expected frequency of some tests. Helpful Hint: Recognize that high utilization of tests attracts attention; documentation supporting need to perform and repeat tests is critical to support medical necessity and claim for reimbursement. Bundling The Centers for Medicare and Medicaid Services (CMS) instructs the MACs to treat some concurrent procedures as a bundle for payment purposes. This means that no separate payment is made for the test outside of the bundled procedure. In addition, some procedures are considered mutually exclusive with others. This means that, when two procedures or tests are performed on the same day on the same patient, only one of the procedures will be paid; generally the one of lesser value. The National Correct Coding Initiative (NCCI) is the regulation that updates these payment rules, usually on a quarterly basis. Some MACs have published local policies with additional limitations beyond the NCCI edits. Since April 2003, minimal eye exams (99211), performed by a medical assistant or technician, are bundled with most concurrent diagnostic tests except the following ultrasound procedures: 76512, 76513, 76514, and 76516. Examinations, except 99211, or consultations by a physician on the same day as a diagnostic test are not bundled. Another visit code, the glaucoma screening benefit (G0117), is bundled with both exams and other ophthalmic services. Some diagnostic tests are bundled with other tests but not with visit codes. For example, fundus photography (92250) is mutually exclusive with scanning computerized ophthalmic diagnostic imaging (92135) and is bundled with ICG angiography (92240). Helpful Hint: Become familiar with the tests that may not be billed with one another due to the NCCI edits. CONCLUSION Ophthalmology has a diverse assortment of options for both office visits and diagnostic testing in its arsenal. Utilization of tests continues to increase, which likely will lead to additional regulations. To keep it simple, remember that each test not personally performed by the physician requires an order with medical rationale and an interpretation. Following the guidelines for appropriate office visit codes, diagnostic testing, and modifiers will lead to more accurate claims and more timely payment of claims. 2008, BSM Consulting 9

COURSE EXAMINATION 1. To be considered valid for CPT code selection, documentation of the slit lamp exam is best described with (select one): a. Discrete documentation of pertinent positive findings for each portion of the slit lamp exam; negative findings can be left blank. b. A comment such as, all aspects of the slit lamp exam were within normal limits. c. Pertinent positives and negatives with an itemized list of all elements of the slit lamp exam. d. A comment citing only positive findings. 2. Most physicians utilizing a blank sheet of paper to document an eye exam will itemize all aspects of the eye exam. 3. You recently upgraded your charts to include much more detail concerning patient history and exam. (choose one): a. As long as all required elements are documented in the history and exam, you can charge the highest level E/M code. b. Not a concern. You can use the eye codes exclusively and avoid all the headaches associated with E/M codes. c. You should have purchased an EMR system instead. A computer system is much more detailed and methodical than a paper record. d. Good, but the decision making aspect of each encounter has an important bearing on the selection of an E/M code, not just the history and exam. 4. Illegible chart entries jeopardize continuity of care. 5. Your patient returns for yearly check up wants new glasses. She has no visual complaints, no chronic diseases, and no recent injuries. You find incipient cataracts and you update her glasses; she leaves with a new Rx. This patient has a medical plan and a vision plan. How should this office visit be handled? (select one): a. Use ICD-9 code 366.12 (incipient cataract) and file a claim with her medical plan. b. Payment for this routine exam is the patient s responsibility. c. Use a refractive diagnosis and file a claim with her vision plan. d. Since you didn t obtain an Advance Beneficiary Notice prior to the visit, neither plan may be billed. 6. Use an intermediate eye exam to report an office visit that is not comprehensive. 2008, BSM Consulting 10

7. Comprehensive eye exams and intermediate eye exams (920xx) require documentation of an external exam. 8. It is highly unlikely that an ophthalmologist could ever justify using the highest level E/M code (99205, 99215, 99245) for an eye exam. (choose one):. These exams require 45-60 minutes of face-to-face time between the physician and patient.. A small percentage of patients have extremely serious eye disease and associated comorbidities that justify level 5 E/M codes. c. True. Doctors don t document enough to merit this reimbursement. d. True. Professional societies and payers warn against using these codes. 9. Auditors likely will question the authenticity of an EMR note when a patient s return encounters contain the exact same notations for each and every visit. 10. A patient calls your billing office complaining about his bill. He states his primary doctor referred him to your office because he had headaches, and his medical insurance rejected the claim as non-covered for a routine exam that included a diagnosis of refractive error. You should: a. Change the ICD-9 code to 784.0 (headache) and send a corrected claim to the insurance company. b. Suggest the patient purchase a vision plan for future visits such as this one. c. Speak with the doctor and discover another diagnosis that was not written in the chart so you can file a new claim. d. Explain that the headaches were caused by refractive error and that the claim was filed properly. 11. A written request for a consultation is only a Medicare requirement, and commercial payers do not expect that a written request exists. 12. In a shared medical record, it is acceptable for the referring physician to document the request for consultation in the treatment plan. 13. According to Medicare s supervision regulation, it is acceptable to perform a visual field without a physician present in the office. 2008, BSM Consulting 11

14. Which level of supervision does gonioscopy require: a. General supervision. b. Direct supervision. c. Personal supervision. d. No supervision designation is assigned to this test. 15. You are a retina specialist. Before you see patients with diabetic retinopathy, you have standing orders for an FA to be performed on both eyes. (select one): a. Medicare will reimburse you for the fluorescein angiograms for this diagnosis. b. You must see the patient before ordering the FA. c. You must be present in the room when the FA is performed. d. All of the above. 16. An order for a diagnostic test may be written on the superbill; it s not necessary to write it in the medical record. 17. The glaucoma specialist writes CWCF or WNL or stable for all diagnostic test interpretations. A commercial payer requests a series of records for review: a. This is not Medicare, so you should not worry about specific documentation requirements. b. The payer likely will determine that this documentation is insufficient and request a refund. c. Before sending out the records, you should have the specialist add to his interpretations to strengthen them. d. You will be fine as long as you send along an abbreviation key so the auditor knows what CWCF means. 18. Test interpretations must be documented on a separate sheet of paper to be considered appropriate for reimbursement purposes. 19. Which of the following diagnostic tests is designated as bilateral within the Medicare program: a. Corneal topography. b. Fluorescein angiography. c. Extended ophthalmoscopy. d. SCODI. 20. The physician s order states: FA OU, OD transit OS, suspected BRVO OD, perform comparison study OS. Which statement is true: a. Medicare reimburses for both eyes regardless of findings. b. FA is a bilateral test. c. If no disease exists in the left eye, the claim should be filed for right eye only. d. It is acceptable to file the left eye with a rule-out BRVO diagnosis. 2008, BSM Consulting 12

21. Medicare reimbursement for unilateral tests performed on both eyes is 150% of the allowed amount for one eye. 22. Your slit lamp exam reveals cataracts OU. The ophthalmoscopic examination of the fundi was negative, but you perform fundus photography (CPT 92250) OU to obtain baseline photographs. How should you file your claim with Medicare: a. 92250 and diagnosis 366.16 (nuclear cataract). b. 92250 is not billable to Medicare because the retina is normal. Don t file a claim. c. The fundus photography is reimbursed as an incidental component of today s eye exam; it s bundled. d. 92250-GA The fundus photo is payable by the patient as a non-covered service if an Advance Beneficiary Notice is signed before the procedure is performed. 23. Gonioscopy may be performed and billed to Medicare at every glaucoma follow-up exam, regardless of findings. 24. You are a cataract surgeon and plan to implant a presbyopia-correcting IOL for your patient who meets coverage criteria for cataract surgery with an IOL. Which of the following test(s) is covered by Medicare prior to implanting this unique IOL? (select one): a. Corneal topography (92025) b. A-scan biometry (76519) and IOL Master (92136) c. A-scan biometry (76519) or IOL Master (92136) d. Refraction and wave front aberrometry (92015-22) 25. Following an eye exam and extended ophthalmoscopy, a retina specialist routinely orders an FA, FP, and OCT for patients with wet AMD on the same day. Which statement is correct: a. This combination of services is medically necessary for wet AMD and the claim will be reimbursed. b. FP and OCT are mutually exclusive with each other. c. EO and FP are mutually exclusive with each other. d. FP is bundled with FA. 2008, BSM Consulting 13