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

2. 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. Both of us do write for Optometric Journals and Rebecca is a consultant for Eye Care Centers, PA

3. 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, Heart of America, 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

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

5. Coding Basics- Don’t Fall Asleep

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

7. CPT Procedure Codes Identifies physician services and procedures
Copyright held by the American Medical Association
Updated yearly through CPT Editorial Process
AOA Represented
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.

8. ICD-10-CM Diagnosis Codes
Identify diagnoses for purposes of medical records and reimbursement
Oversight by the World Health Organization
Changes effective October 1 every year
Notes
THE ICD-9 diagnosis codes are used to identify the reason you performed a procedure or provided a service. The World Health Organization has oversight over these diagnosis codes. The US Department of Health and Human Services update them yearly for our use. When changes are made, these changes are effective on October 1 every year.

9. ICD-10-CM Diagnosis Codes
Code to the highest level of specificity
Unspecified codes going away
Find diagnosis in Alphabetical Index
Verify diagnosis code in Numerical Index
Pay attention to place holders
Conjunctivitis example

10. Supply of Ophthalmic Materials & Some Services
Medicare and Medicaid
HCPCS Codes V2020 – V2799
HCPCS Codes Sxxxx
Other Carrier’s
CPT Series;
Supply of Material
Contact Lens and Spectacle Services
Ocular Prosthetics and Therapy Products

11. Disclaimers for Presentation

12. 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?

13. Interpretation of Testing
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

14. AOA Coding Today Home

15. From AOA Coding Page https://www. aoa
Click

16. AOA Coding Today Tutorials
Log in upper right
Same as AOA Log in if does not take you into AOA Coding Today site

17. Click here
AOA Coding Today: E&M

18. AOA Coding Today: CPT then Medicine then Ophthalmology
Click here

19. AOA Coding Today Ophthalmology
Click here
Prime Section

20. AOA Coding Today Ophthalmology Notes
CPT Introduction to Ophthalmology code set

21. AOA Coding Today General Ophthalmologic Codes

22. AOA Coding Today 92004

23. AOA Coding Today Society Notes

24. AOA Coding Today CPT Assistant

25. AOA Coding Today Quality Measures

26. AOA Coding Today ICD-10

27. AOA Coding Today CPT Modifiers

28. AOA Coding Today HCPCS Modifiers

29. AOA Coding Today Bundling Matrix

30. AOA Coding Today Bundled OK

31. AOA Coding Today Bundled Modifier

32. AOA Coding Today Bundling Not Allowed

34. Glaucoma Suspects
Hi Coding Team, we’ve had some medical insurance deny H which I thought was the correct code for Glaucoma suspect (I forget the actual description for the code). We have been using H (pre glaucoma) recently but thought the first code was the more correct of the two (since that is what is auto coded from my EMR). I’d love to hear which would be better to use. 
Thanks!

35. Glaucoma Denied
I am getting angry with my patient’s insurance company denying all of my glaucoma suspect patients that I am running electrodiagnostic tests on. I just spent a ton of money to buy it because I was told I could make money while helping my patients. What is up with this?

36. VEP for Glaucoma
Why new CPT III code for VEP with glaucoma or glaucoma suspect diagnosis? - Cost issue raised by CMS
Literature presented was not strong enough for CPT panel to meet Category I code level
Trend in Local Carrier Determination to exclude this use of VEP
Must work with EACH carrier on this issue
Alert AOA Third Party Center to any private insurers who exclude VEP for glaucoma

37. 78,177
14,372
20% Usage for
glaucoma

38. ERG for Glaucoma
Trend in Local Carrier Determination to exclude this use for Glaucoma too
No new codes yet-But new ERG codes created
Must work with EACH carrier on this issue
Alert AOA Third Party Center to any private insurers who exclude ERG for glaucoma

39. General Ophthalmologic
If a Medicare patient went somewhere and got an exam and came to us 2 months later for a 2nd opinion on glaucoma suspect, can we do another 92004? We have never seen this patient before. Will we get paid?

40. General Ophthalmologic
As long as Dr does the required components of the comprehensive general ophthalmologic examination, there is no limit to doing the per patient. It is limited only by new vs. existing and what the doc did on that visit.

41. General Ophthalmologic #2
Question: My doctor saw a patient on 7/26 for a diabetic comprehensive eye exam. The patient was unable to be dilated that day and came back in for DFE on 8/10. My doctor says he can charge the patient for this visit, I say no he cannot because it is part of the comprehensive exam. Who is right?

42. General Ophthalmologic #2
You are right....if he used a or
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new/established patient, 1 or more visits

43. Wording creating confusion Get the FACTS!
CPT® is ONLY official definition for codes
CPT® code wording is ONLY official definition for codes
CPT® code introductions are NOT official definitions- only to further explain code use
92012: Official Code Wording – established patients
Ophthalmological services: medical examination and evaluation, with
initiation or continuation of diagnostic and treatment program
92012: Introduction to Code Wording – established patients
Evaluation of new/existing condition complicated by new diagnostic/management problem not necessarily related to primary diagnosis

44. Plaquenil Use
WHAT DX CODE IS USED FOR PLACQUINIL USE OU THANKS

45. Plaquenil Use Z79.899 Other long term (current) drug therapy
PLUS the underlying medical condition.

46. Plaquenil: New Guidelines
Maximum dosage: 5 mg/kg of actual body weight
Baseline screening before or within 1 year of initiation:
Fundus examination
SD-OCT
Visual field testing All but Asian for Asian
After 5 years use: Subsequent screening examinations
Visual field testing
Additional testing as needed: fundus autofluorescence, multifocal ERG

47. Plaquenil New Guidelines
High-risk category - annual or more frequent screening intervals
Higher than maximum daily dose-actual weight
Renal disease
Concurrent tamoxifen and hydroxychloroquine use -5x risk
Concurrent macular disease
Hepatic disease and age not considered risk factors

48. Medicare Glasses
I am a Medicare provider but don't participate in Noridian for the glasses after cataract surgery. I was given a form from Medicare that the patient can fill out and send in to Medicare themselves to get reimbursement. I then give them a 20% discount. I verified with two different Medicare employees that this was ok. I had a patient recently call and say their claim was denied because they were told they need a certificate of necessity saying that glasses were needed after the surgery. I have never had to do that before and can't find a "certificate of necessity" on their website. Do you know what this is?

49. Medicare Glasses
You cannot provide glasses after cataract surgery unless you are a certified DMERC provider, period. There are no exceptions. You need to either become credentialed with DMERC or have the patient sign an ABN stating they are waiving their right to file this Medicare benefit and they cannot file it. Option B on the ABN. You keep a copy and they receive a copy.

50. OCT Photos
My doctor just bought one of the new OCT Photo machines and wants to bill for both on the same day. I remember someone saying you can use a 59 modifier to do that but not sure how. Can you tell me?

51. Modifier 59 Definition
Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances
Modifier 59 should not be used to bypass a Procedure to Procedure (PTP) edit unless the proper criteria for use of the modifier are met.
Documentation in the medical record must satisfy the criteria required by any NCCI (National Correct Coding Initiative) associated modifier that is used.

52. Modifier 59 History
Most widely used modifier according to the Centers for Medicare & Medicaid Services (CMS)
Associated with considerable abuse
High levels of manual audit
Triggers reviews and appeals
Results in civil fraud and abuse cases

53. Modifier 59 New CMS Guidance
Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site. (See example 5-Modifier 59)
Modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ

54. Clinical Decision
We know that using modifier 59 has potential to trigger audits
NCCI policy statement seems to give provider some wiggle room to use -59 modifier
Providers need to use caution if choose to use modifier 59
Coding Experts recommend that scans be performed on different visits to avoid potential for audits.

55. Modifier 59 Changes Since January 5, 2015 - new X code modifiers
Intended to more clearly define “Distinct Procedural Service”
Rules for use have not been written

56. New Modifiers Further Defining Modifier 59
X modifiers meant to define subsets of Modifier 59
X modifiers provide more precise coding options
CMS acknowledges that increased education is needed
CMS only modifiers – CPT manual has not been changed

57. New Modifiers – X(EPSU) Modifiers
XE Separate Encounter:
Service that is distinct because it occurred during a separate encounter

58. New Modifiers – X(EPSU) Modifiers
XS  Separate Structure:
Service that is distinct because it was performed on a separate organ/structure

59. New Modifiers – X(EPSU) Modifiers
XP Separate Practitioner:
Service that is distinct because it was performed by a different practitioner

60. New Modifiers – X(EPSU) Modifiers
XU Unusual Non-Overlapping Service:
Use of a service that is distinct because it does not overlap usual components of the main service.

61. New Modifiers - X(EPSU) Modifiers
CMS continues to recognize Modifier 59
Instructions state that 59 should not be used when a more descriptive modifier is available
Providers should not use modifier 59 and a new X modifier together for the same code

62. Modifier 25
Question: Should modifier 25 be added to the E&M on when it is rendered in addition to an examination such as 92004, 92014, 92002, 92012? My office staff has received different answers to this from different insurers. Thank you

63. Modifier 25
No modifier is needed with diagnostic testing when done with general ophthalmologic examinations.
Regarding Modifier 25-it is specific to E&M with Procedures (surgeries)
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

64. Unknown Diagnosis
Question: Is it ok to use blurred vision as chief complaint for an exam even if the patient has no complaints? The argument is that they have blurred vision with out correction.
Thanks for your help!

65. Unknown Diagnosis
You essentially answered your own question by if the patient has no complaints. then they have no complaint

66. HIPAA
Question: Is my computer repair company classified as a business associate under HIPPA? Sometimes he will take the computer to his shop.

67. HIPAA
The answer really depends on if he has access to the secure data. If it is password protected and he doesn't have the password, then it might be acceptable, but in all actuality, it is simple to develop a document of safety to protect you both.

68. Refraction
We have a patient who had cataract surgery at an outside facility and we did NOT co-manage. She came to us to get a refraction because the provider who did the surgery does not do refractions. Her surgery date was 05/04/ Can we bill the patient for the refraction or does it fall under the 90 day global period?

69. Refraction
If all the doctor is doing is the refraction, then you should bill it so directly to the patient, regardless of within post op period or not. Refraction is never covered by Medicare, even during post op period.

70. Refraction #2
Question: Hi! We are seeing that several/most BCBS Ins plans are now including the refraction into the office visit. Some of the plans actually cover the How do you handle this? Can we just not bill the and bill the patient? Please advise. Thank you!

71. Refraction #2
There are two points here. First is the inclusion of into another code. This is a HIPAA violation and should be reported to your state association third party coordinator. Regarding the not charging to an insurance company and then directly to the patient, that is a problem. You are contracted to charge the insurance company first. You can use an ABN to state that you think it may not be covered and then charge the patient after the EOB denies.

72. Special Ophthalmologic
Question: We use a CT machine to do contact measurement-K's-billed as and a phoropter to do refractions--billed as Recently we purchased an autorefractor-which gives us refraction and k measurements. The doctor will still be going refractions with the phoropter. Can we still bill with the autorefractor if we are only using the k results from it? Is there a special cpt for an autorefractor? How is this done correctly?

73. Special Ophthalmologic
92025 is for corneal topography, NOT keratometry. If the device has the ability to do topography also, and there is an physician order, medical necessity and report, then the doctor can use that machine.
SORRY THERE IS NO CODE FOR AUTOREFRACTOR.
Computerized corneal topography, unilateral or bilateral, with interpretation and report
Source: 2016 CPT®
(Do not report in conjunction with )
(92025 is not used for manual keratoscopy, which is part of a single system Evaluation and Management or ophthalmological service)
Lay Description
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.

74. Special Ophthalmologic #2
Question: Good morning,
I have a question regarding documentation and billing for posterior vitreous detachments. If a patient comes in with symptoms of flashes and floaters and we dilate, take optos photos and do the comprehensive examination but find no tears and only a PVD on BIO, SLE and Optos are we incorrect to bill retinal photos with the diagnosis of PVD? I only consider doing this when I capture the floater or weiss ring on optos. If there is no visual of the floater, I do not consider billing retinal photos. It is my rationale that we have ruled out any tears or detachments and have identified the cause of the patient's symptoms with a comprehensive look at the retina and have captured it on the optos photos. I am only uncertain about billing for retinal photos because the defect is in the media and not the retina. It has however affected the retina and caused the patient's symptoms. I would just like to get your opinion on this scenario rather than just assume I am doing it correctly. Thank you for your time.

75. No Rule Out
The problem is that there is no rule out and if you are unable to visualize a retinal, choroidal or optic nerve condition, it is not appropriate to bill fundus photography. Some carriers do allow for vitreous changes to be documented by photography, but again, the purpose of documentation is to help you with treatment and management, not to show that there was no problem. It is our opinion that you should only be billing for photos when you found pathology, not searching for it.

76. Oculoplastic Referrals
I have had several patients that have had blepharoplasty recently that did not have visual fields done but said the insurance company covered it. When I called the plastic surgeon, they said it wasn’t needed anymore. How is that possible?

77. New Guidelines for Blepharoplasty
CGS: Complaint - Physical findings - Visual fields
Noridan: Complaint - Physical finding - Photos
WPS: Complaint - Physical findings - Visual fields – Photos
Cahaba: Complaint – Physical findings – Visual fields - Photos
Palmetto: Complaint - Physical findings - Photos
5 Carriers with LCD for Blepharoplasty
2 have eliminated Visual Fields requirement

78. Surgical Coding
Question: we filed a Medicare Claim with date of service July 3rd. A Sunday night (on a holiday weekend). We filed (after hours svc), (corneal fb removal) and (bandage cl). Medicare denied the after hours service and the bandage lens, saying they were included in the fb removal. This cant be right!
Any hints? Denial code M80 was used on both -not covered when performed during the same session as processed service.

79. Surgical Coding
Yes this is correct for Medicare. Medicare does not pay after hours care and, for a foreign body excision, bandage CL is considered a dressing and is included in the procedure.
NCCI-2014

80. Low Vision Coding
As a low vision specialist, do I need to have a patient fill out an
ABN form for my services that are NOT covered by Medicare as there is no code that exists?
I am referring to a fee I charge for determining, designing, measuring and fabricating a custom low vision device.
Also, since Medicare does not pay for low vision devices, like a full
diameter telescope with a reading cap or a microscope, do you need to bill Medicare for the 92355, telescope or other compound lens system, when they do not pay for these devices?

81. Low Vision Answer
As another LV Provider I really have a grip on your concerns.
Specific to an ABN, the answer is a definite yes. Even though you may not believe that a code exists, an auditor (or I) could argue that it would be covered under an E&M code (992XX) or a Ophthalmologic unspecified code (92499). Rather than argue the reimbursement and time issues, you need to look at the requirements and what we do.

82. Low Vision Answer
Regarding the or 92354, those codes are not for the device but for the dispensing (along the lines of what you are mentioning above). The devices use HCPCS codes such as V2600, V2610 or V Here it gets a little tricky as this is can fall under a DME claim and may be a completely different carrier. In these cases, we get the ABN again and then do submit to get denied. It shows the patient that you are not trying to rip them off for not submitting.
Hope that this helps although I know it is not what most docs want to hear.

83. Now it’s Your Turn
Ask Away

84. Resources AOA CODING PAGE http://www.aoa.org/coding
Link to AOA CODING TODAY ON RIGHT HAND SIDE OF SCREEN
AOA HIPAA GUIDANCE
AOA HIPAA FREQUENTLY ASKED QUESTIONS
HHS HIPAA PAGE
CMS PHYSICIAN RESOURCE PAGE

85. QUESTIONS?? http://www.aoa.org/ask-the-coding-experts

86. THANK YOU!!