Key Elements to Effective Medical Eye Care Coding and Billing

1. Key Elements to Effective Medical Eye Care Coding and Billing

2. When a Patient Enters Your Practice ? What does the patient want? What does the patient need? What do you perform or provide for the patient? What are the patient expectations? What would you want if you were the patient?

3. Obtaining Third Party Information Seek information as soon as possible in the process • Telephone-appointment scheduling • In person-copies of vision and/or medical plan cards and/or plan information pages Don’t expect the patient to know their plan or coverage Be familiar with your local area companies and their plan coverage

4. Obtaining Third Party Information cont. Verify coverage (obtain authorization as soon as possible) Depending on the nature of the visit, determine if medical plan deductibles have been met and determine any co-payments Doctor and staff must exhibit confidence about the practice’s role in medical eye care and medical plan activities

5. Advance Beneficiary Notice (ABN) • First issued October 1, 2002 • Used for services and materials • Not required for items excluded by statute, such as refraction, contact lenses not covered and eyeglasses not covered • Submit claims with -GA modifier • New ABN @ www.cms.hhs.gov/bni

6. Health Care Procedural Coding System (HCPCS) Level I HCPCS • CPT-4 Procedure codes Level II HCPCS • Alpha-numeric codes to allow billing of supplies, such as V2200 bifocal lenses Level III HCPCS • Local codes

7. ICD Diagnosis Codes International Classification of Diseases (ICD)

8. Diagnosis Codes • Developed and controlled by the World Health Organization (WHO) • The key to payment of billed procedure codes • Linked codes to procedure codes • Valuable to payers to track conditions and statistics • Change to alpha-numeric ICD-10 in 2013

9. Diagnosis Codes • HHS has established that ICD-10 codes be used by health care providers to report diagnosis with procedures beginning October 1, 2013 • ICD-9 contains 17,000 codes where ICD-10 will increase to 155,000 codes • Introduction to HIPAA 5010 at www.CMS.gov/MLNMattersArticles • AOA Third Party Center will provide educational materials-Be proactive!

10. Glaucoma H40 Glaucoma Excludes: absolute glaucoma (H44.5) congenital glaucoma (Q15.0) traumatic glaucoma due to birth injury (P15.3) H40.0 Glaucoma suspect Ocular hypertension H40.1 Primary open-angle glaucoma Glaucoma (primary)(residual stage): · capsular with pseudoexfoliation of lens · chronic simple · low-tension · pigmentary H40.2 Primary angle-closure glaucoma Angle-closure glaucoma (primary)(residual stage): · acute · chronic · intermittent H40.3 Glaucoma secondary to eye trauma   Use additional code, if desired, to identify cause. H40.4 Glaucoma secondary to eye inflammation Use additional code, if desired, to identify cause. H40.5 Glaucoma secondary to other eye disorders   Use additional code, if desired, to identify cause. H40.6 Glaucoma secondary to drugs   Use additional external cause code (Chapter XX), if desired, to identify drug. H40.8 Other glaucoma H40.9 Glaucoma, unspecified

11. ICD-9 Codes International Classification of Disease, Ninth Edition Diagnosis Codes • Typically, a 5 Digit Code with a Decimal Point • 123.45 Can be a 4 Digit code, however be suspicious • 123.4

12. ICD Diagnosis Codes • List primary diagnosis code first and all other ICD codes after • Use most detailed and specific code(s) possible for each submission • List all pertinent diagnosis for each patient for claims • Some medical plans reject refractive diagnosis • Most vision plans today DO NOT reject medical diagnosis • Many vision plans require the submission of all applicable ICD diagnosis codes for all patients (refractive and medical) • Avoid xxx.9 codes whenever possible • Codes may need to be line item specific for procedures linked to different diagnosis

13. ICD Diagnosis Codes cont. • Vitreous Degeneration • 379.2-Disorders of vitreous body • 379.21-Vitreous degeneration • 379.9-Unspecified disorder of the eye and adnexa Verify coverage (obtain authorization as soon as possible)

14. V-Diagnosis Codes • V43.1-Pseudophakia • V58.69-Encounter-long-term (current use) of other (high risk) medications • V65.5-Person with feared complaint in whom no diagnosis was made • V67.51-Follow-up exam following completed treatment with high risk medication(s)

15. V-Diagnosis Codes cont. • V71.8-Observation and evaluation for other specified suspected conditions • V72.0-Special examination of eyes and vision • V80.1-Special screening for glaucoma • V80.2-Special screening for other eye conditions

16. Diabetes Diabetes Mellitus-ICD 250.xx • 250.0_-Diabetes w/o complication or manifestation • 250.5_-Diabetes with ophthalmic manifestations • 5th digit • 0-Type 2 or unspecified- not stated as uncontrolled • 1-Type 1-not stated as uncontrolled • 2-Type 2 or unspecified- uncontrolled • 3-Type 1-uncontrolled

17. Diabetic Retinopathy If diabetic retinopathy is present, appropriate coding is to list 250.5x plus Type of diabetic retinopathy present • 362.03-Not otherwise specified (NOS) • 362.04-Mild Non-proliferative • 362.05-Moderate Non-proliferative • 362.06-Severe Non-proliferative • 362.07-Diabetic Macular Edema

18. Selecting The Appropriate Procedure Code Evaluation/Management EM • Determine extent of History • Determine extent of Examination • Determine extent of Medical Decision Making Identify appropriate Category of Service • Ophthalmological (must meet requirements and definitions listed) • “S” Code • Determine extent of History • Determine extent of Examination • Determine extent of Medical Decision Making • Consultation

19. Utilization Patterns Medicare-Ophthalmology-2008 * Combined utilization of E/M and Eye Codes

20. Utilization Patterns Medicare-Optometry-2008

21. New Patient Codes Combined 92004/99203-75% 92004-65% 99203-10% Established Patient Codes Combined 92014/99214-50% 92014-41% 99214-9% Utilization Patterns - Optometry

22. Develop Your Practice Metrics Ocular Surface Disease/Dry Eye • Reported prevalence in the population = 25-30% • What is your percentage of OSD work-ups and treatment? • Office service follow-up (99212-99214) • Dilation and irrigation (68801) • Punctal occlusion (68761)

23. Develop Your Practice Metrics cont. Glaucoma • Reported prevalence in the population = 1-3% with some population segments as high as 11.5% • What is your percentage of glaucoma work-ups and treatment? • Office service follow-up (99212-99214) • Visual field analysis (92083) • Gonioscopy (92020) • Serial tonometry (92100) • Fundus photography (92250) • Scanning laser (92135) • Pachymetry (76514) Decreases

24. ? “The Great Debate” Vision Plan or Medical Plan Billing Decreases

25. Case Example Patient presents vision plan card (has PPO Managed Health Care Plan) and is seeking new Rx • Ocular Surface Disease that appears inflammatory based • A quality refraction is completed and Rx determined History and clinical findings reveal: What options for billing exist?

26. Case Example cont. • Bill comprehensive examination to Vision Plan • Self-refer/reschedule for OSD work-up Option 1 Option 2 • Bill comprehensive examination to PPO • Refraction (92015) to Vision Plan • Self-refer/re-schedule for follow-up to OSD treatment plan

27. Billing Considerations ? Increases Is your office a participating provider on the PPO medical plan What is the time of the year What were the patient’s expectations entering the office Does the Vision Plan have a primary eye care program to allow extended medical eye services to be billed Is the billing option presented consistent with other payer types in the practice Decreases

28. ? Increases Who is the Ultimate Decision Maker of What Plan Will Be Billed Decreases • The Holder of the Coverage!

29. Billing Considerations Confidence Increases • Explain findings as your clinical tests progress • Stop and recommend course of care as well as coding/billing • Establish expectations for care and schedule Communication to patient/family Decreases • Re-schedule as indicated by condition(s) Managing the schedule

30. Unfortunate Example Monday, May 05, 2008 – xx Dept of Insurance xxxx-area Optometrist Guilty of Insurance Fraud Totaling Nearly $11,500. Dr. xxx xxxx faces six to 12 months in prison. xxxx – xxx xxxx, a xxxx-area optometrist investigated by the xx Department of Insurance for insurance fraud, pled no contest today to a Bill of Information charging Him with one count of insurance fraud, a felony of the fifth degree thereby waiving his right to be indicted. xxxx was found guilty of illegally billing insurance entities Anthem, United Health Care and Tricare and fraudulently receiving nearly $11,500 for personal gain. Department Fraud and Enforcement attorney xxx xxxx served as special prosecutor in the case before the xxxx County Court of Common Pleas. xxxx sentencing hearing is scheduled for June 17 at 10 a.m. He faces a potential prison sentence from six to 12 months. xxxx used several fraudulent schemes, including charging patients $21 for a visual fields test procedure. He would, in some cases, advise the patients that their insurance would not cover this test but that it was important that they have it. The patients would pay him their co-payments as well as the $21. He would only show the co-payments on the insurance submissions then bill the insurers and pocket the money. He would also bill for a bogus mucous membrane test that required a special allergen – which the office did not have – to be inserted into the eye membrane. xxxx who suspect insurance fraud should call the Departments fraud hotline at 1-800-xxx-xxxx.. Increases Decreases

31. Increases Decreases Medical Eye Care

32. Medical Necessity is: Medicare: • Services that are proper and needed for the diagnosis or treatment of the patient’s medical condition(s), are provided for the diagnosis and direct care and treatment of the patient’s medical condition(s), meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or physician. Other coverage definitions: • Treatment based on evidence-based medical standards, or the treatment is considered by most physicians in your community to be clinically appropriate Increases Decreases

33. ? What is of Primary Importance for Billing a Medical Visit A Chief Complaint

34. Chief Complaint “The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician’s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye exam with no specific complaint, the expenses for the examination are not covered even though as a result of the examination the doctor discovered a pathological condition.” Bottom Line: To qualify for reimbursement, you must establish a link between the chief complaint and the submitted diagnosis Increases Decreases

35. Selecting and Using Evaluation/Management (E/M) Codes

36. Elements of E/M Coding History* Nature of Presenting Problem Examination* Time Medical Decision Making* Coordination of Care Decreases Counseling * Key Elements

37. Time • “When counseling or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face to face time…), then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members. The extent of the counseling and/or coordination of care must be documented in the medical record.” Decreases

38. Typical Times in CPT-4 • 99205-60 minutes • 99204-45 minutes • 99203-30 minutes • 99202-20 minutes • 99201-10 minutes • 99215-40 minutes • 99214-25 minutes • 99213-15 minutes • 99212-10 minutes • 99211-5 minutes (Non physician) Increases Decreases

39. Documentation Guidelines Increases • Adds detail to E/M original definitions • Need to obtain a copy of 1995 or 1997 Guidelines and be aware of what standards you will be held to • A copy of the 1995 and 1997 guidelines are available at CMS website at: http://www.cms.hhs.gov/MLNProducts/downloads/referenceII.pdf Decreases

40. Minimal-One self-limited or minor problem Low-Two or more self-limited or minor problems; One stable chronic illness; One acute uncomplicated illness or injury-Treatment w/ OTC medication Moderate-One or more chronic illness…; Two or more stable chronic illnesses; Undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury- Treatment w/ prescription medication High-One or more chronic illnesses w/ progression; Acute or chronic illnesses or injuries that pose a threat to life or bodily function; abrupt change to neurological status-Treatment w/ therapy that requires toxicity monitoring Medical Decision Making Source: 1997 Documentation Guidelines

41. Consultations Decreases

42. Consultation Requirements Consultation-…Service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Increases • Request • Render Opinion • Report of findings to requesting physician or other source Decreases Needed elements:

43. The Federal Register, Vol. 74, No. 226 posted November 25, 2009, contains CMS’ final decision to eliminate both outpatient consultations (99241 – 99245) and inpatient consultations (99251 – 99255) for payment purposes. CMS cites lack of understanding and confusion over their use as the rationale to eliminate them. Physicians should use either evaluation and management (992xx) or ophthalmology (920xx) codes in place of outpatient consultations. E/M Consultation Codes

44. Increases Decreases Special Ophthalmological Services

45. Other Specialized Services 92020-Gonioscopy (B) Increases 92025-Corneal Topography (B) 92081-Visual Field (B) Decreases 92082-Visual Field (B) Must use multiple readings (3 minimum) in the same 24-hour period 92083-Visual Field (B) 92100-Serial Tonometry (B)

46. Other Specialized Services cont. 92135-Scanning computerized imaging with interpretation and report (U) • Bundled by many payers with 92250 or 92083 if billed at same session (use an ABN!) • Not truly indicated in advanced disease 92225-Ophthalmoscopy extended, with retinal drawing, interpretation and report, initial (U) Decreases 92226-Ophthalmoscopy, subsequent (U)

47. Other Specialized Services cont. 92250-Fundus photography w/ interpretation and report (B) Increases 92283-Color vision examination, extended (B) 92285-External ocular photography w/ interpretation and report for documentation of medical progress (B)

48. OCT-Anterior Segment • 0187T-Scanning computerized ophthalmic diagnostic imaging, anterior segment with interpretation and report, unilateral • Coverage and payment for Category III codes remains at carrier discretion Category III Code Decreases

49. Billing Specialized Services Baseline or routine testing is inappropriate Increases • Must base test order on medical necessity • Be aware of coding/testing requirements from payer • Bill with office service, if appropriate, and use modifier where indicated • Use interpretation and report where needed List in clinical records the order for the test Decreases

50. Interpretation and Report • Indications for performing the test • Test results with notation of reliability • Use of test results in treatment and management of the condition • Initiate treatment or plan to repeat testing or other care • Where possible, initial and date the test form Decreases