Ask the AOA Coding Experts: Top Ten Questions Harvey Richman, O. D Ask the AOA Coding Experts: Top Ten Questions Harvey Richman, O.D. Rebecca Wartman, OD Doug Morrow, OD

Disclaimers for Presentation All information was current at time it was prepared Drawn from national policies, with links included in the presentation for your use Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations Prepared and presented carefully to ensure the information is accurate, current and relevant No conflicts of interest exist for the presenter- financial or otherwise

Disclaimers for Presentation Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services AOA, AOA-TPC, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein

AOA Third Party Center Coding Experts Harvey Richman OD Rebecca Wartman OD Douglas Morrow OD

Coding Basics- Don’t Fall Asleep

Coding Systems CPT Procedure Codes ICD-9-CM/ICD-10-CM Diagnosis Codes What You Do ICD-9-CM/ICD-10-CM Diagnosis Codes What You Find HCPCS Codes What You Supplied or Do Modifiers What’s Different There are three coding systems in place at the current time. The CPT system, the ICD-9 system and the “Hick pick” codes

CPT Procedure Codes Identifies physician services and procedures Copyright held by the American Medical Association Updated yearly through CPT Editorial Process Changes effective January 1 every year CPT Procedure Codes identify each and every service provided to a patient. This code set is owned and copyrighted by the AMA. Codes are continuously added, deleted, and changed in a complex, but open, process. A new edition is published annually.

Question 1A Interpretation of Testing I just bought an OCT. The company installed and taught us how to use it but they didn’t teach us how to interpret it. Can you teach us?

Question 1A Interpretation of Testing NO! We cannot teach you how to interpret your OCT findings BUT We can give you coding guidelines for OCT use AND Resources to learn how to interpret findings: Lectures Websites Manufacturer materials Experience

Question 1 Dilation I was told by one of my friends that I should only use intermediate level codes for routine eye exams but I dilate all my patients. Doesn’t that make them comprehensive exams?

Question 1 Dilation Not necessarily! New Patient vs. Established General Ophthalmic Services Codes New Patient vs. Established Comprehensive vs. Intermediate Elements of services Guidance on coding

General Ophthalmologic Services CPT ® Codes Note: Current Procedural Terminology(© American Medical Association) is the only accepted source of definitions for these services. 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient 92004 ;comprehensive, new patient, 1 or more visits

General Ophthalmologic Services CPT ® Codes 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient 92014 ;comprehensive, established patient, 1 or more visits

Comprehensive Ophthalmological Services General Ophthalmologic Services Comprehensive Ophthalmological Services 92004 & 92014 Introduction in CPT ® General evaluation of the complete visual system (1 or more sessions) Includes: History General medical observation External examination Ophthalmoscopic examination Gross visual fields Basic sensorimotor examination Often includes: Biomicroscopy Examination with cycloplegia or mydriasis Tonometry. Always includes: Initiation/continuation of diagnostic and treatment programs

Intermediate Ophthalmological Services General Ophthalmologic Services Intermediate Ophthalmological Services 92002 and 92012 Introduction in CPT® Evaluation of new/existing condition complicated by new diagnostic/management problem not necessarily related to primary diagnosis Includes History General medical observation External examination Adnexal examination May Include Other diagnostic procedures Mydriasis w/ ophthalmoscopy Always includes Initiation/continuation of diagnostic and treatment programs

General Ophthalmologic Services Diagnostic and Treatment Program Includes, but not complete list: Prescription of medication Special ophthalmological diagnostic or treatment services Consultations Laboratory procedures Radiological services

General Ophthalmologic Services How Differ from E&M Intermediate & Comprehensive Ophthalmological Services: Medical decision making cannot be separated from examining techniques Itemization of service components is not applicable Slit lamp examination Keratometry Routine ophthalmoscopy Retinoscopy Tonometry Motor evaluation

General Ophthalmologic Services Intermediate Some Medicare Carriers further define what constitutes Intermediate and Comprehensive Ophthalmic Examinations Source appears to be CPT Assistant Article August 1998 and the CPT introduction and definitions This review helps in determining intermediate vs comprehensive service levels COMPREHENSIVE

General Ophthalmologic Services Ten Elements of Ophthalmologic Examination Confrontation fields Eyelids/adnexa Ocular motility Pupils/iris Cornea Anterior Chamber Lens Intraocular pressure Retina (vitreous, macula, periphery, and vessels) Optic disc (Should be 12 elements including acuity and bulbar and palpebral conjunctiva but not always listed)

General Ophthalmologic Services Comprehensive examination eight or more elements including: Fundus examination with dilation** Motor evaluation **Note that CPT definitions do NOT require dilation but some carriers do- some with further statement “with dilation unless contraindicated”

General Ophthalmologic Services Intermediate Examination Seven or fewer elements AND Additional Ophthalmic Tests

Question 2 Refraction Since insurance is not covering, my patients are getting mad about my refraction and contact lens exam fees. Is there a way that I can incorporate them into my eye exam fee?

Question 2 Refraction Refraction and HIPAA Contact Lens Codes Inducement Violations S-Codes Presentation of fees to patient

Special Ophthalmological Services General Ophthalmologic Services Special Ophthalmological Services 92015 to 92140 Reported in addition to general ophthalmological services or E&M services Interpretation and report by the physician or QHP is integral part of special ophthalmological services where indicated

Refraction-92015 Determination of refractive state Statutorily not covered by Medicare RVU $20.42 Consider Modifiers GY and 22

Coding Guidelines Refraction not covered by Medicare General Ophthalmologic Services Coding Guidelines Refraction not covered by Medicare May file for denial GY modifier may be necessary indicates that the service is statutorily excluded from Medicare coverage Advanced Beneficiary Notice (ABN)

S-Codes S0620 – routine ophthalmologic examination including refraction, new patient S0621 -- routine ophthalmologic examination including refraction, established patient

Routine Examination Codes? S CODES PROBLEMS No valuation No further definitions Insurers free to interpret at will

Fee Presentation Just because the patient has insurance doesn’t mean that the procedure is covered Know the plans and how to present to patient Plan rules not always HIPAA Compliant

Question 3 Cataract Post op I keep getting denials from Medicare for submission of a second eye cataract post op. What am I doing wrong?

Question 3 Cataract Post Op Modifier Use Surgical Correct Billing Guidelines

Post Op Surgeon -54 modifier indicating surgical care only Post-op period = 90 days 2017 and beyond? Surgery day = Day 0 Transfer of care Transfer date Surgical Procedure Surgical Diagnosis

Post Op-Modifiers -55 modifier -79 modifier RT modifier LT modifier

Key Points Summary Thorough documentation is vital Communication with the surgeon is critical Surgeon must document the exchange of care Patient must understand exchange of care process Patients must have choice for post-operative care Communication with the patient is critical ALWAYS act in the best interest of the patient These key points are very important to remember when performing post-operative care: Thorough documentation in the patient chart is vital. Communication with the surgeon is critical in the exchange of post-surgical care The surgeon must document the exchange of post-surgical care The patient must understand of the post-operative care process and which doctor is responsible for care at a given time. Patients must have a choice of who delivers the post-operative care Communication with the patient is very critical. Both the surgeon and the optometrist must always act in the best interest of the patient.

Question 3A Cataract Post Op How do you handle a patient that is covered by a commercial carrier, is under 65 and has cataract surgery and the insurance company tells you they will not pay for co-management? Do I bill E&M’s for the post op? Do I fight with the carrier?  Or both?  

Question 3A Cataract Post Op Insurance company policies Options? Bill Patient Bill Surgeon Write Off

Question 4 Fundus Photography My camera company told me that since my camera does a better job of looking for retinopathy then I do, that I can I use that instead of dilating my diabetic patients and bill 92250. It makes sense.

Question 4 Fundus Photography Diabetic Eye Exam Requirements PQRS requirements

Diabetes and Retinal Examinations American Diabetes Association and the National Institutes of Health’s positions retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the onset of diabetes Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination soon after diagnosis. Subsequent examinations for type 1 and type 2 diabetic patients are generally repeated annually

Diabetes and Retinal Examinations American Diabetes Association and the National Institutes of Health’s position Photos are not a substitute for a comprehensive eye exam

CPT® 92250 considered medically necessary to monitor pathology 92250 Purpose CPT® 92250 considered medically necessary to monitor pathology   Reimbursed by Medicare and other third party payers per guidelines for fundus photography 

92250 Technology CPT® defines code 92250 as “Fundus photography with interpretation and report” and makes no mention of the technology used to acquire the image. There has been some confusion based on one CMS carrier, Palmetto GBA, which has an LCD (local coverage determination) where it is stated in the Coverage Indications, Limitations, and/or Medical Necessity section that “Fundus photography uses a special camera to photograph structures behind the lens of the eye including vitreous, retina, choroids, and optic nerve. This procedure does not include laser scanning of the retina.”  A few other CMS carriers add variations of the following: “…..use of a retinal camera….and photograph”.  Those terms can be potentially confusing since technology to create a photograph has changed significantly in the last several decades. It continues to be AOA’s position that when billing for any service or procedure, your prudent step is to follow, to the best of your ability, the coding definitions and coverage policies , whether they are by CPT®, a Medicare contractor or a third party payer. 

#5 Routine or Medical A patient came in complaining of flashes of light and red eyes for the past two weeks. After doing a total eye exam, I found that he had a PVD, bilateral cataracts and his corneas were beat from sleeping with his daily disposable contacts. How do I code for my time when he only has Vision Plan X?

Medical vs Wellness Patient with Medical Plan & well vision plan At exam completion, fees are reviewed Patient announces expectation for exam to be covered by his well vision plan WHAT DO YOU DO? Clearly exam has medical presentation, history & exam

Medical vs Wellness Options: Patient with Medical Plan & well vision plan Many offices are faced with this dilemma More and more Medical Plans are adding wellness care Options: Perform well vision exam and reschedule for medical Inquire upon patient arrive which plan intend to use Bill Medical Carrier →exam & Bill well vision →glasses Bill Medical carrier & cross file to well vision plan for copay, refraction and glasses, if allowed

Well Vision Examinations Coding approaches across nation Internally use S code for all well vision Internal code only Converted to “plan accepted code” (92 series?) All routine patients –same exam=same fee concept Payment method disregarded in coding 92 and 99 would be used only for medical Refraction separate Concern: “different” charge for same code when actually filed to insurance

Current Advice Doctors need to make hard decisions on how will handle BEFORE they occur Doctors need to thoroughly and completely TRAIN staff on policies Doctors need to thoroughly and completely read Well Vision Carrier policies Doctors need to carefully consider WHICH Well Vision Plans they will accept

Guiding Principles to Consider The chief complaint & examination findings should RULE examination content AND coding My vision has gradually gotten worse, especially at near, no known ocular disease Findings- presbyopic shift, no medical issues → Well vision examination Findings – early ARMD → Medical examination Examination content and technique for each similar but findings require more extensive examination, more knowledge and more risk Medical examination leads to other testing, often

Guiding Principles to Consider Plans accepted MAY have contract limitations on when must use well vision plans and if coordination of benefits may occur Some plans allow Coordination of benefits (COB) Some plans are changing their guidelines to force medical care under the well vision plan service Some plans are rolling more medical testing under their well vision plans Some plans are requiring the listing of medical diagnoses in addition to the refractive diagnoses applicable PROVIDERS MUST READ AND UNDERSTAND THEIR CONTRACTS SO ARE ABIDING BY THE RULES!

Guiding Principles to Consider Develop office policies and approaches to this common issue THEN stick to them!! Avoid making rules for the rare exceptions Ensure excellent education of staff and patients Understand the consequences of your office policy decisions- you cannot go wrong with well thought out polices Accept the fact that you may lose a few patients Review your policies yearly to ensure these policies still meet the needs of your practice

Guiding Principles to Consider Do apply the CPT codes and coding rules correctly and across the board Remember waiving copays without clear case by case hardship documentation is considered fraud Remember that waiving charges for procedures without clear case by case hardship documentation is considered fraud Remember to develop policies that prevent fraud and abuse and uphold HIPAA rules

Question 5A Meaningful Use I want to meet Meaningful Use, but it is too hard for my staff to enter into the computer. Can I just check off the boxes because I write it all down correctly on the record?

Question 5A Meaningful Use Meaningful Use 2 guidance AOA resources Meaningful Use audits across the country

Question 6 Foreign Body If a patient comes in with a complaint of something flying in his eye and I find a foreign body, how do I bill it? I heard someone once say you can’t bill an office visit, is that true?

Question 6 Foreign Body Modifiers Surgical Correct Billing Guidelines New Patient vs Established Patient ICD-10-CM rules

Foreign Body Removal 65205 Conjunctival FB Removal, superficial 65210 Conjunctival FB Removal, embedded 65220 Corneal FB Removal w/o Slit Lamp 65222 Corneal FB Removal w/ Slit Lamp The procedure codes used for the removal of foreign bodies include 65205 to describe the removal of a superficial conjunctival foreign body and 65210 for the removal of an embedded conjunctival foreign body. 65210 included the removal of concretions, sub-conjunctival foreign bodies and non-perforating sclera foreign bodies. These codes are used per foreign body. When more than one foreign body is removed in a single session, the subsequent procedures are usually paid at a lower rate. Corneal foreign body removal is coded using 65220 with the foreign body is removed without the use of a slit lamp while 65222 is used to describe the removal of a foreign body with the use of a slit lamp. The more common procedure would be with the use of a slit lamp.

Foreign Body Removal ICD-9 diagnosis codes ICD-10 diagnosis codes 930.1 Conjunctival Foreign Body 930.0 Corneal Foreign Body ICD-10 diagnosis codes T15.00 Foreign body in cornea, unspecified eye T15.00XA Foreign body in cornea, unspecified eye, initial encounter T15.00XD Foreign body in cornea, unspecified eye, subsequent encounter T15.00XS Foreign body in cornea, unspecified eye, sequela Procedure billed stand alone Procedure billed with E&M code The diagnosis codes used to support the removal of a foreign body is 930.1 for conjunctival foreign bodies and 930.0 for corneal foreign body. The CPT code would usually be billed as a stand alone code if the appointment is made specifically for the procedure. If the patient is being seen with complaints about the eye and a corneal foreign body is discovered as causing the symptoms, then an E&M code with a -25 modifier can be used to bill both procedures. The patient record should clearly indicate the process used to arrive at the diagnosis before the surgical procedure was performed. Specifics about multiple procedure fee reductions and a more extensive list of supportive diagnostic codes can be found in your carrier’s guidelines.

Multiple Foreign Body Removal Same code for one or multiple foreign bodies -51 modifier (multiple procedures) -50 modifier (bilateral procedures) When performing removal of multiple foreign bodies, use the same 60000 code as you would for a single foreign body removal. Some carriers will pay per foreign body with others will pay per eye. If you are filing for more than one foreign body in a single eye, you would use the -51 modifier indicating the number of foreign bodies and indicating which eye. If you are removing foreign bodies from both eyes use the – 50 modifier for a bilateral procedure. If multiple foreign bodies are encountered in one eye, use the single procedure code. If extensive time is required use the appropriate modifier (22) with the surgical codes to allow for adequate re-imbursement.

Other Corneal Procedures 65430 Scraping of cornea, diagnostic 65435 Removal of corneal epithelium The 65430 code is defined as; scraping of the cornea, diagnostic, for smear and/or culture and is used for the treatment of a corneal condition that requires more advanced treatment (ie: corneal ulcer). The 65435 code is defined as removal of corneal epithelium, with or without chemocauterization (abrasion, curettage) and is used when debridement of the cornea is required for treatment of a recurrent corneal erosion. Each of these procedures would be billed once per eye.

Supporting ICD-10 Codes Scrape and Culture Cornea +H16.00 Unspecified corneal ulcer Debridement of Cornea H18.83 Recurrent erosion of cornea B00.52  Herpesviral keratitis H18.51  Endothelial corneal dystrophy Fuchs' dystrophy The most common use of corneal scraping for diagnostic purposes would be for corneal ulcers. The diagnostic codes that would support debridement of the cornea for treatment would be recurrent corneal erosion, herpes simples keratitis or corneal dystrophy. A more extensive list of supporting diagnostic codes can be found in your carrier’s guidelines.

Billing Surgical Codes Surgical codes are “stand alone” codes Not usually billed with E&M codes -25 modifier if E&M visit results in decision for surgical procedure Surgical codes are generally “stand alone” procedures and are not typically billed with a 92000 or 99000 examination code but there are exceptions. When a provider is evaluating a patient with a complaint and determines that a surgical procedure is needed, the surgical procedure can be performed the same day. When billing for this situation, the appropriate -25 modifier must be used in order to receive payment for both the exam code and the procedure code. It will be important to document this fully in the patient record.

Question 7 Multiple Procedures My glaucoma patient can only come in once per year because their daughter visits only in the summer. I need to do ophthalmoscopy, fundus photos, gonioscopy, pachymetry, fields and OCT on that day or else she will never get it done. I was told that we can do that. What should I do?

Question 7 Multiple Procedures Multiple Procedure Payment Reduction Modifiers Medical Necessity Local Coverage Determination (LCD) for Services That Are and Are Not Reasonable and Necessary Patient education

Multiple Procedure Payment Reduction Modifications 20% reduction to practice expense component for 2+ service(s) furnished by a physician or group practice in an office setting on same day

Multiple Procedure Payment Reduction Modifications April 1, 2013, American Taxpayer Relief Act of 2012 applied up to 50% multiple procedure payment reduction modifications (MPPR) 20% reduction to technical component for 2+ diagnostic ophthalmology services furnished to same patient-same physician-same day 50% reduction for 2+ surgical procedures furnished to same patient-same physician-same day

Multiple Procedures on Same Day 76510-76513 A and B Scans 76514 Pachymetry 92025 Corneal Topography 92060 Sensorimotor exam 92081-92083 Visual Field exams 92132-92136 Scanning Laser 92228 Remote imagining-retinal 92235-92240 FA 92250 Fundus photos 92265-92275 Oculoelectromyography 92283 Color vision 92284 Dark adaptation 92285 External photos 92286 Spectular Microscopy

Question 8 Keratoconus Contact Lenses I finally had a patient with keratoconus that the insurance company paid for the visit with the new code. The problem was that the carrier did not pay for the contact and said it is not the patient’s responsibility. What can I do?

Question 8 Keratoconus Contact Lenses 92072 92071 HCPCS code options Private coverage options Medicare options-DMERC

92072 CPT® Fitting of a contact lens for management of keratoconus, initial fitting. For subsequent fittings, please use either the 9921X or 9201X codes. Report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code.

92072 The follow up for the contact lens fitting would be billed with E&M codes. Once the initial contact lens fitting is complete, 92072 cannot be used again after this initial fitting. If the keratoconus patient needed to be treated (fit) again the fitting 92072 would not be used, but instead use an E&M code and 92310 for the fitting.

92071 CPT® Fitting of a contact lens for treatment of ocular surface disease Report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code. This is the appropriate code to use for fitting a bandage contact lens.

92071 The 92071 code would be used when a patient has a traumatic injury (abrasion) or another corneal disorder such as a recurrent corneal erosion, filamentary keratitis or bullous keratopathy. The patient or payer would be billed for the appropriate office visit code, either a 92000 or 99000 code and the 92071 code for the treatment with the bandage contact lens.

92071 The provider may also use a bandage contact lens after the removal of a corneal foreign body (65222). In this case the 92071 code can be billed as a bandage, but some payers will deny the 92071 because the 65222 is valued with a wound dressing included in the payment for the foreign body removal.

Question 9 ICD-10-CM Revisited I keep seeing these webinars and articles about ICD-10-CM. If I only see regular patients, do I need to worry about this?

Question 9 ICD-10-CM Revisited Federal Law AOA Eye-learn Vision Plans and coding EHR Vendors CMS website CDC ICD-10-CM website

Z-Codes Z01.00 Encounter for examination of eyes and vision without abnormal findings Encounter for examination of eyes and vision NOS Z01.01 Encounter for examination of eyes and vision with abnormal findings Use Additional: code to identify abnormal findings

Z-Codes-Examples Z01.01 Encounter for examination of eyes and vision with abnormal findings Use Additional: code to identify abnormal findings H40.053 Ocular hypertension, bilateral H25.13  Age-related nuclear cataract, bilateral H52.13  Myopia, bilateral ??

ICD-10-CM Resources American Optometric Association www.aoa.org/coding CDC ICD-10-CM Official USA site http://www.cdc.gov/nchs/icd/icd10cm.htm 2014 release of ICD-10-CM at bottom of page has all the downloads ICD-10-CM Guidelines  [PDF - 512 KB] ICD-10-CM PDF Format ICD-10-CM List of codes and Descriptions (updated 7/3/2013) CMS ICD-10-CM information https://www.cms.gov/Medicare/Coding/ICD10/index.html X World Health X but Use for general training only http://apps.who.int/classifications/apps/icd/icd10training

Question 10 Non Covered Procedures My doctor went to a lecture recently and told us we can be charging patients for photography of the cornea for our dry eye patients. When we do, the insurance company keeps denying. Can you help?

Question 10 Non Covered Procedures Anterior Segment imaging –spectral microscopy 92286 External Ocular Photography 92285 Medical Necessity LCD vs. CPB Glaucoma Suspect Macular Drusen

0330T digital interferometry, an eye tear film imaging method used to assess the lipid layer of the tear film of the eye in order to measure the thickness of the layer Category III code is usually not reimbursable by third party payers but the filing of the charges allows the CPT® editorial panel to gauge the frequency of use

Medical Necessity A service that appears to meet the technical requirements for coverage may be excluded if that service: not generally accepted as safe and effective not supported in peer-reviewed medical literature not medically necessary in a specific case, or for a specific medical diagnosis furnished at a level, duration, dosage or frequency not appropriate for a specific patient or clinical condition

Medical Necessity not furnished in manner consistent with standards of care not furnished in appropriate medical setting (place of service) furnished in manner primarily for patient/provider convenience device not approved by FDA or not included in an FDA trial test or service considered obsolete by the medical community, and replaced by more efficacious services

Just because you get paid doesn’t make it right Resources Medicare Carrier CMS CCI edits Private carrier guidance Ask the Coding Experts AOA Coding Today State Association Third Party Center

RIGHT????? Finally Any last questions? All you coding issues are solved! Right! RIGHT?????

THANK YOU