2. Special Ophthalmologic & Beyond
Dr. Harvey Richman, OD, FAAO, FCOVD
Diplomate American Board of Optometry
AOA Third Party Center Executive Committee
“CodeHead”

3. Disclaimers
Medicare policy changes frequently so links to the source documents have been provided for your reference.
This presentation is prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
Every reasonable effort has been made to assure the accuracy of the information.
Ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

4. Disclaimers
This presentation is general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.
The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at on the CMS website.
Current Procedural Terminology (CPT) is copyright by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

5. 92000 Codes Special Ophthalmological Services
Describe Services in which a special Evaluation of part of the visual system is made, which goes beyond the services, or in which special treatment is given. Special ophthalmological services may be reported in addition to the general ophthalmological services or evaluation and management services

6. 92000 Series Codes Extended Ophthalmoscopy* Fundus Photography*
Not a Routine BIO
Angiography (Fluorescein / Indocyanine Green)
Fundus Photography*
Scanning Laser Technology*
Color Vision Examination
Gonioscopy
External Ocular Photography*
Sensorimotor Evaluation
Visual Fields*
* Means Report Needed.
Document Everything

7. Effect of Lenses
With Lenses
Without Lenses

8. Refraction-92015 Determination of refractive state
Statutorily not covered by Medicare
RVU $38.09
Consider Modifiers
GY and 22

9. Refraction 92015 By CMS Statute a Non-Covered Service
Patient Responsibility
ABN Not Required but Useful
GY Modifier
Multilevel Refraction Codes 92015?
Phoropter
Trial Frame
Telescope

10. Modifiers 21-Prolonged E&M Services 22- Increased Procedural Services
When the face to face service is prolonged or otherwise greater than that usually required for the highest E & M service within a given category. A report may be appropriate.
22- Increased Procedural Services
When the work required to provide a service is substantially greater than what is typically required. Documentation must support the substantial additional work and the reason for the additional work. (Time, difficulty of procedure, severity of patient condition)
Not to be used with E & M

11. Gonioscopy
92020
Gonioscopic exam to diagnose injury or disease in the anterior chamber of the eye, performed under local anesthetic due to necessity of placing specialized lens directly on the eye to obtain a clear image
Bilateral Procedure Code
LCD Utilization

12. Topography
92025
Computerized corneal topography, unilateral or bilateral with interpretation and report
Detection of subtle corneal surface irregularity and astigmatism
Report one time only
Computerized corneal topography, unilateral or bilateral, is also known as computer assisted keratography or videokeratography. This is a method of measuring the curvature of the cornea. A special instrument projects rings of light onto the eye, which are reflected back to the device, which then creates a color-coded map of the cornea's surface with a cross-sectional profile. Defects such as scarring, astigmatism, and other abnormal curvatures of the eye can be detected using this method, which is commonly performed prior to corrective eye surgery, such as LASIK.

13. Indications & Limitations of Coverage:
Post penetrating keratoplasty
Post kerato-refractive complications
Post op irregular astigmatism
Corneal dystrophy, bullous keratopathy
Complications of transplanted cornea,
Keratoconus

14. Reasons For Denial: Non-covered for refractive procedures
Often billable privately for contact lens evaluations or included in examination fee

15. Sensorimotor Exam
92060
Sensorimotor examination (i.e. of the movement of the eye), conducted by taking measurements as the eyes focus on different locations or through one or more prisms. Searches for deviations in normal eye movements, which may result from injury or disease. Includes interpretation and report.

16. 92071
Fitting of a contact lens for treatment of ocular surface disease
Report materials in addition to this code, using either or the appropriate HCPCS Level II material code.
This is the appropriate code to use for fitting a bandage contact lens.

17. 92072
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 or the appropriate HCPCS Level II material code.

18. Visual Field Examinations
92081 Limited, unilateral or bilateral,with interpretation and report; examination
92082 Intermediate, unilateral or bilateral, with interpretation and report
92083 Extended, unilateral or bilateral, with interpretation and report

19. Indications & Limitations of Coverage
Necessary to establish a diagnosis
Monitor a course for treatment
Determine if a change in therapeutic plan

20. Indications & Limitations of Coverage
medically necessary to diagnose and follow retinal disorders
92083 diagnosis or follow-up of glaucoma

21. Coding Guidelines All services are considered bilateral
-50 modifier is not appropriate
-52 modifier if only doing one eye

22. Blepharoplasty Guidelines
Visual field examinations to determine the need for blepharoplasty are sometimes performed twice, once with the eye(s) taped and immediately repeated without the eye(s) taped. In this situation, the repeated service should be submitted with CPT modifier 76 on a separate detail line.

23. Serial Tonometry 92100 (Separate Procedure)
With multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure)
Bilateral Code
Modifier if appropriate

24. Scanning Laser Tests
Confocal laser scanning ophthalmoscopy (topography)
Optical Coherence tomography

25. Coding guidelines 92225, 92226, 76512, 92250 59 modifier usage
Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral
Using either a 52- LT or RT modifier if reduced
CPT codes not covered with SLT:
92225, , , 92250
59 modifier usage
GA modifier usage with ABN

26. 92132-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL
Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma
Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction
Iris tumor
Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber

27. 92132-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL
Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A-scan or IOL master.
Certain exceptions that must be determined on a case-by-case basis with the appropriate documentation.

28. 92133Glaucoma Indications
SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; OPTIC NERVE
Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the nerve fiber even in advanced cases of glaucoma.
It is expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma.

29.  MILD visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees)  ICD 9 365.71

30. MODERATE visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees) ICD

31. SEVERE visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees) ICD9 365.73

32. Glaucoma Severity/Staging Level Scanning Laser Frequency
The current frequency limitations for Scanning Laser for most regions are:
Mild or Suspect Glaucoma 1 Time per year
Moderate Glaucoma 2 Times per year
Advanced or Severe Glaucoma NO Scanning laser. Up to Visual Fields per year

33. Utilization Guidelines-GLC
Although CMS guidelines state
Only two exams/eye/year are allowed for the patient who has or is suspected of having glaucoma
Most LCD state once per year to follow pre-glaucoma patients or those with “mild” damage
One or two tests per year for patients with “moderate damage,”
followed with SLT or visual fields
if both SLT and visual fields are used, only one of each tests
“Advanced damage,” field testing preferred by Medicare guidance

34. 92134-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA
Retinal disorders are the most common causes of severe and permanent vision loss. These technologies are valuable tools for the evaluation and treatment of patients with retinal disease, especially macular abnormalities.
These imaging techniques are useful tools to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of therapy.

35. 92134-SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL; RETINA
It is expected that only one exam/eye/2 months would be required to manage the patient whose primary ophthalmological condition is related to a retinal disease.  However, for those patients who are undergoing active treatment for macular degeneration or diabetic retinopathy one exam/eye/month may be appropriate for the management of their disease.
The use of fluorescein angiography, indocyanine green angiography and SCODI to study the patient’s same eye per clinical encounter will NOT be authorized. However, SCODI and fluorescein angiography may be obtained on the patient’s same eye per clinical encounter if the medical record substantiates the need for both studies.

36. Utilization Guidelines-AMD/DR
Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease
One exam/eye/month is allowed for the patient who is undergoing active treatment for macular degeneration or diabetic retinopathy

37. Extended Ophthalmoloscopy
Ophthalmoscopy, extended, retinal drawing with interpretation & report; initial
Subsequent

38. Extended Ophthalmoscopy
Reserved for the meticulous evaluation of a severe ophthalmologic problem
Always include indirect ophthalmoscopy & one other method viewing detail
Retinal drawing with detail a must.

39. Coding Guidelines: unilateral procedure
Do not report codes with modifier –50
Service on both eyes, use LT or RT (uncommon)

40. LCD Guidelines
Extended ophthalmoscopy is covered when prolonged time is required for a detailed examination of possible retinal lesions or follow-up of lesions under treatment or surveillance.

41. LCD
The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available to Medicare on request.
For consideration of CPT codes (extended ophthalmoscopy with retinal drawing), retinal pathology must be present to justify detailed examination. The retinal drawing should be labeled and include major landmarks, lesions and surrounding pathology. As an example, a drawing should provide sufficient detail as to the extent of a retinal detachment or the location of retinal holes in relation to major structures. Areas of traction, vitreous opacities, hemorrhage, etc. should be drawn and labeled to facilitate follow-up, referral to another physician, or purposed surgical treatment of the patient. A brief verbal interpretation of the findings is also required.

42. Documentation Guidelines???
Drawing has to be a certain size (no)
Observation with two or more lenses (maybe)
Scleral Indentation must be done
Colored Drawings with colored pencils (match international recommendations).
Must have interpretation and report as well as orders!

43. Documentation Requirements:
Reason for performing the examination
Technique used
Drawing of the retina showing anatomy seen including the pathology
Legible narrative report of the findings
Documentation supporting medical necessity must be submitted

44. 92250:Fundus Photography Bilateral Code
Fundus photography with interpretation and report
Bilateral Code

45. Photography Document abnormalities
Check carrier’s medical policy for limitations or restrictions of coverage
Obtain filing requirements from carrier for bilateral or multiple procedures

46. 92250 Utilization Guidelines
Fundus photography. Generally, it is not medically necessary to repeat fundus photography more often than every 2 years for follow-up of stable glaucoma. Repeat photographs for retinopathy are rarely necessary.

47. 92275-ERG Electroretinography with interpretation and report
Bilateral Code
No LCD-YET
Most TPP experimental except for plaquenil
Not for EOMs

48. Anterior Segment Photography
92285
External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, gonio-photography, stereo-photography)
Medicare Fees National Non-Facility Fee $43.58

49. External Ocular Photography 92285
Bilateral Code
Check carrier for limitations or restrictions of coverage
NCCI
92020, 99211, 15820, 15821, 15822, 15823
Modifier indicator of “1” on 92020, 99211, 15820, 15821, 15822, 15823
append appropriate modifier if rendered together

50. LCD Definition
External ocular photography is covered when a special camera is used to obtain magnified photographs of lesions (e.g., the cornea, iris or lids) for the purpose of following the patient's condition. Medical quality images may be of digital, Polaroid Macro 3 SLR or equivalent. Simple Polaroid photographs for the purpose of documenting for medicolegal purposes or preauthorization (e.g., gross trauma, amount of ptosis or redundant lid tissue) are not separately reimbursable since they are not medically necessary.

51. 92310 Fitting of one eye, append -52 modifier
Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia:
Fitting of one eye, append -52 modifier
Non Covered Service for Medicare
Non-Facility Fee $91.81
HCPCS: V codes

52.
Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, … one eye two eyes corneoscleral lens

53. 92314 Fitting of one eye, append -52 modifier
Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes, except for aphakia:
Fitting of one eye, append -52 modifier
Non Covered Service for Medicare
Non-Facility Fee $72.64
HCPCS: Vcodes

54.
Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, … one eye two eyes corneoscleral lens

55. Contact Lens Evaluations
92325
Modification of contact lens (separate procedure), with medical supervision of adaptation
Lay description-Modification of contact lens, typically by grinder or polisher, to provide a better fit
Non-Facility Fee $29.13

56. Contact Lens Evaluations
92326
Replacement of contact lens under current prescription (due to damage, loss, etc.).
Non-Facility Fee $34.66

57. 95930 Visual Evoked Potential
Visual Evoked Potential testing central nervous system, checkerboard or flash
Bilateral Code
General Supervision
Special Training?
No Utilization Guidelines YET

58. 60000 series codes Surgery - Eye and Ocular Adnexa
Global surgical periods apply to all surgical procedures.
Each of these procedures has a designated global post-operative period ranging from zero days to ninety days. Services related to the surgery cannot be billed separately during the global period.

59. CPT Surgical Package
The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:

60. Co-Management of Surgical Procedures
Management of a surgical procedure is the primary responsibility of the operating Surgeon. Physicians who perform surgery, and furnish all the usual pre and post-operative work should bill for global surgery using the proper CPT Surgical code (s) after appending the appropriate modifier to the surgical CPT code.

61. Co-Management of Surgical Procedures
Transfer of global surgery must be
Clinically necessary and appropriate.
The Transfer of care is allowed only to protect the interest of the patient.
The physician receiving the patient must be licensed to manage all aspects of the postoperative care, including diagnosing potential complications that would require a return to surgery.

62. Co-Management of Surgical Procedures
Co-management is indicated under any of the following circumstances:**
When the surgeon is unavailable after surgery and the patient’s post-operative care has to be managed by another physician
When the patient is unable to travel the distance to get to the surgeon for F/U care.

63. Co-Management of Surgical Procedures
When the patient elects to have F/U care provided by another provider
When the surgeon practices in a site remote from where the patient recuperates
A second illness has developed which prevents travel to the operating surgeon
Surgery is performed while the patient is traveling, vacationing or living in a distant location

64. 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

65. Multiple Foreign Body Removal
ICD.10 CM Diagnosis Codes
S05.01XA Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter (note: include cause)
S05.01XD Injury of conjunctiva and corneal abrasion without foreign body, right eye, subsequent encounter (note: include cause)
S05.02XA Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter (note: include cause)
S05.02XD Injury of conjunctiva and corneal abrasion without foreign body, left eye, subsequent encounter (note: include cause)
Use modifier 22 for multiple foreign body removals requiring extended period of time

66. Removal of Corneal Epithelium
65435
Removal of corneal epithelium; with or without chemocauterization

67. Epilation of Trichiasis
67820-
When the eyelashes are ingrown or misdirected (trichiasis), the physician uses a biomicroscope and forceps to remove the offending eyelashes.

68. Punctal Dilation
68801
Dilation of lacrimal punctum, with or without irrigation
It's best not to perform the dilation on the same day as insertion. Don't include the procedure as a routine component of code 68761
Bilateral use with modifier 50
Medicare Fees National Non-Facility Fee $106.87

69. Punctal Probing
68810
Probing of nasolacrimal duct, with or without irrigation
Medicare Fees National Non-Facility Fee $230.80

70. Punctal Occlusion 68761 Closure of the lacrimal punctum; by plug, each
10 Day Post Op period
Medicare Fees National Non-Facility Fee $131.50

71. Punctal Occlusion Reporting
100% First Puncta
50% Second Puncta
25% Third and Fourth Puncta
Modifiers Needed for Multiple Plugs
E1-E4 50 51 99

72. ICD-X-CM Diagnosis Codes
Superficial keratitis, unspecified
Punctate keratitis, Thygeson’s superficial punctate keratitis
Keratoconjunctivitis sicca, not specified as Sjögren’s
Exposure keratoconjunctivitis
Conjunctival xerosis
Tear film insufficiency, unspecified dry eye syndrome
Stenosis of lacrimal punctum
Stenosis of nasolacrimal duct, acquired
3Pain in or around the eye
Redness or discharge
Sicca syndrome (keratoconjunctivitis sicca, Sjögren’s disease)

73. Punctal Plug Supply
A4262
TEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACH
Medicare Fees National Non-Facility Fee $0.00
Status B (bundled)

74. Punctal Plug Supply
A4263
PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACH
Medicare Fees National Non-Facility Fee $0.00 (B)

75. Punctal Plug Supply ?
99070
Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)
Medicare Fees National Non-Facility Fee $0.00

76. Administrative Strategies in Coding and Billing
4/28/2017
Diagnostic CPT's
Pachymetry:
CPT 76514
Bilateral.
Billable for Corneal Problems and Glaucoma.
Requires Interpretation
and Report.
David K. Talley, O.D., F.A.A.O.

77. Laboratory Testing 80000 Series Codes
Pathology and Laboratory Testing
Must be CLIA certified facility
Line 23 on HCFA
Clinical Laboratory Institute of America – Apply as exempt

78. Tear Assay
83516
Immunoassay for analyte other than infectious agent antibody, quantitative or semi-quantitative
Used to analyse tear composition for Lactoferrin
CLIA certification is required
Tear Assay is used when analyzing the composition of the tears for lactoferrin. The optometrist will need Clinical Laboratory Improvement Amendments, or CLIA, certification to perform this test. The office will have to be compliant with all the rules surrounding CLIA testing.

79. Tear Assay Bilateral code Paid one time for both eyes
Clinical Lab Fees
2016 Clinical Diagnostic Laboratory (National Limit): $16.12
This code is considered a bilateral code and is paid only once for both eyes. You will not need to file the the –RT or –LT modifier

80. Adenovirus Testing
87809
Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus
Rapid Pathogen Screening
Bilateral code-Paid one time for both eyes
Clinical Lab Fees-2016 Clinical Diagnostic Laboratory (National Limit): $16.76
CLIA certification is required

81. Thanks for your time, now……