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Excellence in Optometric Education

Understanding Medicare Guidelines - 2013. John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute. Excellence in Optometric Education. John A. McGreal Jr., O.D. McGreal Educational Institute Missouri Eye Associates 11710 Old Ballas Rd.

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Excellence in Optometric Education

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  1. Understanding Medicare Guidelines - 2013 John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education

  2. John A. McGreal Jr., O.D. McGreal Educational Institute Missouri Eye Associates • 11710 Old Ballas Rd. • St. Louis, MO. 63141 • 314.569.2020 • 314.569.1596 FAX • mcgrealjohn@gmail.com JAM

  3. 2013 Medicare E/M Guidelines • Compliance • How To Document the Medical Record • How To Select an E/M Codes, eye codes, “S” codes • How To Evaluate your Fees • How To Effectively Co-manage Surgical Cases • How To Increase Revenues • How To Survive an Audit • How To Implement a Compliance Plan JAM

  4. Medicare Part B Deductible • Deductible (Medicare Part B) • Will increase to $147 in 2013 ($7 more); • thereafter increase by annual percentage increase in Part B expenditure JAM

  5. 2006 New ICD-9 Codes • Code first diabetes (250.5) • 362.03 Nonproliferative diabetic retinopathy NOS • 362.04 Mild nonproliferative diabetic retinopathy • 362.05 Moderate nonproliferative diabetic retinopathy • 362.06 Severe nonproliferative diabetic retinopathy • 362.07 Diabetic macular edema • Must report with ICD code for diabetic retinopathy • 362.01 = background diabetic retinopathy • 362.02 = proliferative diabetic retinopathy • 362.03 – 362.06 JAM

  6. Timely Claims Submission • Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service • This change applies to services furnished after January 1, 2010 • Reduces the previous maximum timely filing deadline of 15-27 months JAM

  7. 2011 New CPT Codes • 66761 – Iridectomy/iridotomy by laser surgery per session (instead of one or more, with GD010) • 67220 – Destruction of localized lesion of choroid (ex. Choroidal neovascularization); photocoagulation, one or more sessions • 0191T – Insertion of ant. segment drainage device, without extraocular reservoir, internal approach into TM • 0253T – Insertion of ant. segment drainage device, without extraocular reservoir, internal approach, into SC • 0192T – Insertion of anterior seg aqueous drainage device, without extraocular reservoir, external approach • Ex. EXPRESS Implant JAM

  8. New CPT Codes Scanning laser LCD • 92133 or 92134 and fundus photography are mutually exclusive in CCI edits • CCI assigned an indicator of “1” instead of “0” which means there may be medical indications where it is appropriate to unbundle the two codes • There are a limited number of clinical conditions where both techniques are medically necessary and reasonable on the ipsilateral eye • In these situations, both CPT codes may be reported appending the modifier -59 to CPT code 92250 JAM

  9. 2012 Deleted CPT Codes • 92120 – Tonography with I&R, perilimbal suction method • 92130- Tonography with water provocation • 92070 – Fitting of Contact lens for treatment of disease, including supply of lens JAM

  10. 2012 New CPT Codes • 92071 – Fitting of Contact Lens for Treatment of Ocular Surface Disease • Do not report with 92072 • Report supply of lens separately with 99070 or appropriate supply code • 92072 – Fitting of Contact Lens for Management of Keratoconus, initial fitting • For subsequent fittings, use E/M services or general ophthalmic services (92xxx) • Do not report with 92071, report supply codes separately JAM

  11. 2012 New ICD-9 Codes • 379.27 Vitreomacular adhesions, associated with AMD, DR, PVD • V19.11 Family history of glaucoma • V19.19 Family history of other specified eye disorder JAM

  12. 2012 New ICD-9 Glaucoma Coding • Given great variability of cost of care & resource utilization among glaucoma patients, glaucoma care has been targeted for use of potential value-based modifiers in the future • ICD-9 and ICD-10 codes reflect this and will allow stratification of a patient population • Developed by the American Glaucoma Society (AGS) workgroup, including Drs. Fellman & Mattox • Then enlisted comprehensive ophthalmologists, optometrists, and a few glaucoma specialists to evaluate and test for accuracy using real cases from Dr. J. Stein at University of Michigan JAM

  13. 2012 New ICD-9 Codes – Glaucoma Stages • When coding glaucoma subcategories 365.1-365.6 assign an additional code to identify specific stage of glaucoma (365.7) • 365.70 Glaucoma stage, unspecified • 365.71 Mild stage glaucoma • 365.72 Moderate stage glaucoma • 365.73 Severe stage glaucoma • 365.74 Indeterminate stage glaucoma • Includes sequencing instructions to code first the glaucoma, by type • Report new V19.11 history codes where appropriate JAM

  14. Step One: Code by Type • Only the codes listed here require add-on staging codes • 365.10 Open angle glaucoma, unspecified • 365.11 Primary open angle glaucoma • 356.12 Low tension glaucoma • 365.13 Pigmentary glaucoma • 365.20 primary angle closure glaucoma, unspecified • 365.23 Chronic or primary angle closure glaucoma, unsp • 365.31 Steroid induced glaucoma • 365.52 Pseudoexfoliation glaucoma • 365.62 Glaucoma associated with ocular inflammations • 365.63 Glaucoma associated with vascular disorders • 365.65 Glaucoma associated with ocular trauma JAM

  15. Step Two: Add Stage • Determine severity of glaucoma in worse eye • 365.71 Mild (disc abnormalities consistent w glaucoma but no VFD on SAP or Short wave-length doubling perimetry) • 365.72 Moderate stage (Disc abnormalities consistent w glaucoma and VFD in 1 hemifield, not w/in 5 degrees of fix) • 365.73 Severe stage (Disc abnormalities consistent w glaucoma VFDs in both hemifields, and/or loss w/in 5 degrees of fix in at least 1 hemifield) • 365.74 Indeterminate (VFs not performed yet, or patient incapable of VF testing or unreliable or uninterpretable VFs) • 365.70 Unspecified, stage not recorded in chart • Compliance requires documentation of stage in medical record JAM

  16. Additional Glaucoma Code Changes • 365.01 Open angle suspect, Low Risk (1-2 risk factors) • 365.05 Open angle suspect, High Risk (3+ risk factors) • Risk factors – family history, race, elevated IOP, disc appearance and thin central corneal thickness • 365.02 Primary angle closure suspect (anatomical suspect, narrow angle) • 365.06 Primary angle closure without glaucoma damage (defined as angle damage such as synechia or high IOP, but w/o optic nerve damage) • 365.23 Chronic angle closure glaucoma (angle damage plus optic nerve damage) JAM

  17. 2012 SCODI Update • Medicare carriers have updated their Local Coverage Decisions (LCDs) for scanning computerized digital ophthalmic imaging (SCODI) to include covered diagnosis codes for diagnostic screening of patients taking Hydroxychloroquine (Plaquenil). • Some indicate frequency and some specify spectral domain only • Covered ICD-9 codes are V58.69 High Risk Medications, Current use, and V67.51, Following Completed Treatment with High Risk Medications JAM

  18. 2013 Other Changes • Cataract surgery fees reduced for 66982 & 66984 by 13% • Physician Compare Website – includes name, specialty, education, participation status, status in PQRS & e-prescribing, board certification, additional foreign language, hospital affiliation, EHR incentive program • ICD-9 – NO CHANGES! JAM

  19. Physician Value-Based Payment Modifier • CMS will adjust payment to some physicians based on quality & resource use beginning in 2015 and all physicians by 2017 • Now applies only to groups of 100 or more (originally 25) • Smaller groups (2-99) remain unaffected until 2017 • 3% payment penalty to hospitals began in 2012 for re-admission rates higher than national average • Heart failure • Pneumonia • Myocardial infarction JAM

  20. Reduction in Diagnostic Testing • CMS will decrease payment by 20% of technical component of second and subsequent diagnostic tests furnished by same physician (or physicians in same group) to same patient on same day • Originally set at 25% • A diagnostic service refers to any diagnostic test that has a technical & professional component • CMS indicated they will closely monitor practice changes to bypass multiple payment reductions JAM

  21. Reduction in Diagnostic Testing • 76510 92060 92228 92285 • 76511 92081 92235 92286 • 76512 92082 92240 • 76513 92083 92250 • 76514 92132 92270 • 76516 92133 92275 • 76519 92134 92283 • 92125 92136 92284 JAM

  22. PQRI Name Change to PQRS • CMS continues incentive payments in 2013 • www.cms.gov/PQRI/15_MeasuresCodes.asp • Successful PQRS reporters earn 0.5% in 2013 • Must report on at least 3 measures 50% of the time • Decrease from 80% in 2010 • Report for full year (Jan1-Dec31, 2013) • Incentive payments for years 2014 will be 0.5% • 2015 JAM

  23. PQRS 2013 • In 2015 a 1.5% PQRS payment penalty will be applied, in 2016 this increases to 2.0% • 2013 PQRS participation used to determine cuts in 2015 • Participation means attempting to report at least one PQRS measure between Jan 1 –Dec 31 2013 • Glaucoma staging codes removed • Measure 124: Health Information Technology has been eliminated JAM

  24. OIG Audits / Work Plan • Ophthalmological services – 92xxx codes • Reviewing claims during 2011 • 6.8 billion in claims by eye MDs & ODs • Focus on 92004/92014, other 92- included • E/M Services: Use of modifiers • Modifiers -25 • Bilateral intravitreal injections • Sequestration – 2% payment reductions across the board in Medicare claims beginning April 1, 2013 • Includes a 2% reduction in EHR incentive bonus JAM

  25. OIG Work Plan • Ophthalmological services – New • Reviewing claims during 2011 • $6.8 Billion paid to ophthalmologists & optometrists in 2011 • 8.31% of all claims paid to all physicians in all specialties • 92004 was 12th highest paid code used in all specialties • 66984 was 5th highest paid code • 99xxx E&M codes not included, not specialty specific • E/M Services: Use of modifiers • Modifiers -25 • Bilateral intravitreal injections • http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf JAM

  26. OIG Work Plan • Rank CPT Services • 5 66984 Cat-IOL • 12 92014 Comp eye exam, est pt • 26 92012 Interm eye exam, est pt • 31 92135 Scanning laser • 52 92004 Comp eye exam, new pt • 63 66984 Cat-IOL, complicated • 67 00142 Anesthesia for proc, eye, lens • 73 92083 Visual field, full • 103 92250 Fundus photography • 141 67228 Treatment of exten or prog retinopathy • 148 15823 Blepharoplasty • 178 92136 Ophthalmic biometry w IOL power calc JAM

  27. Recovery Audit Contractors RAC • Evaluating RAC performance 2010 & 2011 • Completed 3 year demonstration project in 2012 • Congress will mandate a nationwide implementation of a permanent RAC program for Medicare part A & B • Mandates by Tax Relief & Health Care Act 2006 and Affordable Care Act • Tool used include comparative billing reports • Shows specific provider billing patterns compared to peers JAM

  28. Health Insurance Portability and Accountability Act of 1996 • President Clinton & USAG J. Reno • #2 priority: prosecution of health care fraud • $104 Million: Appropriations to HHS • $70 Million: OIG • $47 Million: FBI fraud investigation unit • Criminal offenses expanded • $10,000 fine / line item violation • suspension of payment and participation from program • Yielded $23 return on every $1 spent in 1997 JAM

  29. Dead Doctors Billing Scams 2000-2007 • 478,500 false claims • 16,500 dead physicians • $92.8 million in payments just by Medicare • 16% made by doctors dead for more than 10 years JAM

  30. Qui Tam Relaters • Amendment to False Claims Act of 1986 • Encourages private individuals to sue in the government’s behalf • Whistleblowers - 30% of recoveries • $1 Billion paid since 1987 in Qui Tam actions • Compliance Plan • Eliminates aggressive or conservative billing philosophies • Removes incentives for whistleblowers • Improves collections while reducing audit risks JAM

  31. Top 10 Procedure Codes – Optometry Missouri / Jan-June 2007 / 495 Providers • 92014 $1,369,645 • 99214 $ 634,210 • 92004 $ 562,906 • 92012 $ 551,297 • 99213 $ 541,616 • 66984 $ 395,125 • 92250 $ 339,862 • 92083 $ 277,708 • 99203 $ 199,510 • 92135 $ 195,427 JAM

  32. 2012 Comprehensive Error Rate Testing (CERT) • There has been a HUGE increase in CERT audits of E/M services since October 2011 • From April 2009-May 2010, E/M services accounted for 28 billion in Medicare Part B payments • Estimated 8.4% billed incorrectly • Providers encouraged to review 1997 E/M Guidelines for compliance JAM

  33. 2011 CMS Optometry Probe Results • Prepayment review of 100 services from 100 claims • Probe: CPT 99213 (random) • Results • 66% allowed as billed • 34% denied • 23% No documents submitted • 5% Services not documented in medical record • 3% Non-covered services • 3% Not medically necessary JAM

  34. Code Set Adoption in HIPAA • CPT-4: Current Procedure Terminology • CDT: Code on Dental Procedures and Nomenclature • ICD-9-CM (Volume 1,2): International Classification of Diseases (Implementation of ICD-10 is October 1, 2014!!) • ICD-9-CM (Volume 3): inpatient disease codes • NDC: National Drug Code • HCPCS: Healthcare Common Procedure Coding System JAM

  35. Medicare – Just Give Me The Numbers • Longevity Revolution • First year of Baby Boomers hitting 65 years of age • 10,000/day turn 65 years of age • An individual turns 60 years of age every 8 seconds • If you live until age 65, average life expectancy is age 84 • 47, 672,971 Medicare beneficiaries in US • 15% of total population • Cataract surgery is the most common surgical procedure in US in Medicare beneficiaries • Also boasts best outcomes • Lowest complication rate JAM

  36. Medicare – Distribution by Age (2004) • 65-69 23.2 % • 70-74 19.9 % • 75-79 17.3 % • 80-84 12.9 % • 85+ 11.0 % JAM

  37. AOA Optometric Practice Profiles 2005 • VSP – 21% • Other vision plans – 8% • Medicare – 19.1% (fastest growing share of revenues) • Medicare HMOs – 3% • Medicaid – 7% • HMOs (private sector) – 8% • Out of pocket – 35% • Respondents - 90% self-employed, 47% solo, 24% group, 86% male, mean years in practice 24.2 years JAM

  38. INTRODUCTION • CMS • CPT • ICD • Medicare • Major Medical • E/M Coding (99XXX) • Eye Coding (92XXX) • Special Ophthalmic Codes JAM

  39. E/M GUIDELINES • New/Established Patient • Chief Complaint • History of Present Illness • Family History • Past History • Social History • New additions level of education, sexual history, marital status/living arrangements • Review of Systems • Time JAM

  40. E/M DESCRIPTORS • History * • Examination* • Medical Decision Making* • Counseling • Coordination of Care • Nature of the Presenting Problem • Time JAM

  41. CATEGORIES OF SERVICE • Office Visits (E/M Codes) • New 99201-99205 • Estab 99211-99215 • Office Visits (Eye Codes) • New 92002-92004 • Estab 92012-92014 • Consultations (E/M Codes) • ELIMINATED for Medicare, Medicaid, Tricare and Medicare Advantage HMOs and when any of these are secondary payors • Can still be used for other commercial plans JAM

  42. SELECTING AN E/M LEVEL • Identify Category of Service • Identify Extent of History Taking • Identify Extent of Examination • Identify Complexity of Medical Decision Making • Review E/M Descriptors JAM

  43. E/M CODING - OFFICE VISITS • New Patient (3 of 3) • 99201 - PFH / PFE / SDM / 10 • 99202 - EFH / DFE / SDM / 20 • 99203 - DH / DE / LDM / 30 • 99204 - CH / CE / MDM / 45 • 99205 - CD /CE / HDM / 60 JAM

  44. E/M Coding - Office Visits • Established Patient (2 of 3) • 99211 - Minimal / 5 • 99212 - PFH / PFE / SDM / 10 • 99213 - EFH / EFE / LDM / 15 • 99214 - DH / DE / MDM / 25 • 99215 - CH / CE / HDM / 40 JAM

  45. DOCUMENTATION OF HISTORY • Problem Focused History (PFH) • CC / 1-3 HPI • Expanded Problem Focused History (EPF) • CC / 1-3 HPI / Ocular ROS • Detailed History (DH) • CC / 4 HPI / Ocular ROS / ROS-2 / 1 OF 3 PFSH • Comprehensive History (CH) • CC / 4 HPI / Ocular ROS / ROS-10 / 3 OF 3 PFSH (NEW) OR 2 OF 3 PFSH (ESTAB) JAM

  46. Eye Examination Documentation • VA / CVF / Pupils & Iris / Adnexa • Bulbar & Palp Conjunctiva • EOM • SLE: Cornea / Lens /AC • IOP / Optic Nerve / Posterior Segment • Neurologic: Orientation (Time / Place / Person) • Psychiatric: Mood & Affect (Depression /Anxiety /Agitation) JAM

  47. DOCUMENTATION OF EXAMINATION • Problem Focused Exam (PFE) • Limited Exam / l - 5 Elements • Expanded Problem Focused Exam (EPF) • Limited Exam / 6 Elements • Detailed Exam (DE) • Extended Exam / 9 Elements • Comprehensive Exam (CE) • Complete Single System Exam • All Elements JAM

  48. Medical Decision Making • Straightforward (SF) • # Dx / Rx Options - Min / Data - Min / Risk - Min • Low Complexity (LC) • # Dx / Rx Options - Lim / Data - Lim / Risk - Low • Moderate Complexity (MC) • # Dx / Rx Options - Mult / Data - Mod / Risk -Mod • High Complexity (HC) • # Dx / Rx Options - Ext / Data - Ext / Risk - High JAM

  49. Comprehensive Ophthalmological Service 92004 / 92014 • Complete system evaluation, • Need not be performed at one session • Integrated services where med decision making cannot be separated from examination methods • Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy retinoscopy, tonometry, or motor evaluation is not applicable

  50. Comprehensive Ophthalmological Service 92004 / 92014 • Includes history, medical observation, external & ophthalmoscopic examinations, gross visual fields, sensorimotor examination • Often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry • Always includes initiation of diagnostic and treatment programs

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