Part 3 Filing 3 rd Party Claims Addressing: Which Exam Codes Should I Use?Which Exam Codes Should I Use?

Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

Disclaimer The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

vs In general, the codes are more concrete, requiring less subjective judgment In general, the codes are more concrete, requiring less subjective judgment But these concrete requirements may necessitate tests or procedures not required by comparable comprehensive codes. (dilation) But these concrete requirements may necessitate tests or procedures not required by comparable comprehensive codes. (dilation)

vs The codes for a comprehensive exam require a “diagnostic and treatment program” while the codes do not. The codes for a comprehensive exam require a “diagnostic and treatment program” while the codes do not. When following a patient chronic conditions that require… When following a patient chronic conditions that require… no billable diagnostic testing and no billable diagnostic testing and no treatment, no treatment, …it is difficult to code comprehensive codes. …it is difficult to code comprehensive codes.

vs Never examine and bill simply to maximize reimbursement rates… Never examine and bill simply to maximize reimbursement rates… To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges. To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges.

vs Maximum Medicare reimbursement for a comprehensive exam is higher in some cases than an equivalent exam. Maximum Medicare reimbursement for a comprehensive exam is higher in some cases than an equivalent exam. Any such advantage is dependent on your U&C and fees. Any such advantage is dependent on your U&C and fees. – Many OD’s exam fees are not near that Medicare maximum, and to them there seems no $$ advantage in using the fees.

vs But,if the OD’s examination fees are near or above Medicare’s maximum reimbursement level, then But,if the OD’s examination fees are near or above Medicare’s maximum reimbursement level, then – Provider must charge all patients that same amount. – Cannot charge a non-covered patient less.

vs A discount for cash payment day of services by a self-pay patient is probably acceptable… …if it does not exceed 15% to 20%. …if it does not exceed 15% to 20%. Rationale: no billing or insurance claim expenses. Rationale: no billing or insurance claim expenses.

vs Always Bill based on the reasonable and necessary examination you performed and documented considering… Presenting Problem Presenting Problem History History Clinical findings Clinical findings

vs Never examine and bill simply to maximize reimbursement rates… Never examine and bill simply to maximize reimbursement rates… To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges. To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges.

Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3 rd Party Educational Videos. 3 rd Party Services Nebraska Optometric Association