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Excellence in Optometric Education

Understanding Medicare Guidelines - 2008. John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute. Excellence in Optometric Education. John A. McGreal Jr., O.D. Missouri Eye Associates 11710 Old Ballas Rd. St. Louis, MO. 63141 314.569.2020

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Excellence in Optometric Education

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  1. Understanding Medicare Guidelines - 2008 John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education

  2. John A. McGreal Jr., O.D. • Missouri Eye Associates • 11710 Old Ballas Rd. • St. Louis, MO. 63141 • 314.569.2020 • 314.569.1596 FAX • jamod1@aol.com JAM

  3. 2008 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 Understand HIPPA Privacy Rules • How To Implement a Compliance Plan JAM

  4. 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

  5. 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

  6. Medicare Review Strategies - 2008 • Error rates at below 7% nationally • E/M codes represent 75% of errors (highest for Part B) • 10-1 overpayment –underpayment • Insufficient documentation and incorrect coding • OB/GYN specialty highest error rate nationally at 35.75% • Diagnostic radiology specialty highest projected dollars paid incorrectly at 48 million JAM

  7. Top 5 Errors by Profession - 2006 • OB/GYN • Neurology • Chiropractic • Optometry – 11.6% • Nephrology JAM

  8. Medicare Review Strategies - 2008 • E/M established codes • Laboratory • Hospital E/M, subsequent • Consultation codes • E/M new codes • Electrocardiograms • Chiropractic • Rituximab • Hospital E/M, initial JAM

  9. HIPAA in Bite Sized Chunks • Standards for transactions conducted electronically • Standards to protect privacy of personal health information • Standards to protect security of personal health information when stored electronically • Uniform federal identifiers of providers, health plan, employers and individuals JAM

  10. NPI Identifier • Enumerator / National Provider System / ANSI • Must be used by May 23, 2007 • Providers need to apply online at CMS website • Identifiers for providers, health plans, employers and individuals • National Provider Identifier (NPI) • 10 digit string of alphanumeric characters, includes check digit • Format allows 200 billion identifiers without re-using values • Benefits of NPI identifiers • All transactions for ALL health plans • NPI will never change • Facilitates coordination of benefits • Facilitates tracking claims and payments • Facilitates identifying and prosecuting fraud • Start sharing NPIs NOW with consultants & Specialists!! JAM

  11. 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 (Proposal to implement ICD-10) • ICD-9-CM (Volume 3): inpatient disease codes • NDC: National Drug Code • HCPCS: Healthcare Common Procedure Coding System JAM

  12. INTRODUCTION • CMS = Center for Medicare & Medicaid Services (formerly HCFA) - announced June 14, 2001 • Center for Medicare Management - traditional fee-for-service programs • Center for Beneficiary Choices - provide beneficiaries with information on Medicare, MedicareSelect, Medicare+Choice, and Medigap options • Center for Medicaid and State Operations - focus on Medicaid and state administered services JAM

  13. INTRODUCTION • CMS • CPT • ICD • www.icd9coding1.com/flashcode/userRegister.do • Medicare • Major Medical • E/M Coding (99XXX) • Eye Coding (92XXX) • Special Ophthalmic Codes JAM

  14. E/M GUIDELINES • New/Established Patient • Chief Complaint • History of Present Illness • Family History • Past History • Social History • Review of Systems JAM

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

  16. 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) • Office 99241-99245 JAM

  17. E/M Coding - Consultation • Office Consultations • Opinion / Advice • Not Referral • Duration - short • Continuity - expect patient back • Documentation - required JAM

  18. E/M Coding - Referral • Referral • Treatment or Care • Duration - long • Continuity - Do not expect patient back • Documentation - not required, but courtesy • Warning! - carefully consider the language used in the correspondence to your consulting specialists • avoid the term referral, unless that is what you mean! JAM

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. Comprehensive Ophthalmological Service 92004 / 92014 • Complete system evaluation, 8 or more elements • Need not be performed at one session • Integrated services where med decision making cannot be separated from examination methods • Includes history, medical observation, external & ophthalmoscopic, gross visual fields, sensorimotor, biomicroscopy, consultations, dilation (cycloplegia), mydriasis, tonometry, initiation of diagnosis and treatment programs, prescription of medication

  27. Comprehensive Ophthalmological Service 92004/92014 • Always includes initiation of diagnosis and treatment programs • includes the prescription of medication, and arranging for special ophthalmological diagnostic / treatment services, consultations, laboratory procedures and radiological services JAM

  28. Intermediate Ophthalmological Service 92002 / 92012 • Evaluation of new / existing condition, complicated with a new diagnostic or management problem • Integrated services where med decision making cannot be separated from examination methods • Includes history, medical observation, external & adnexal, & other diagnostic procedures, biomicroscopy, mydriasis ophthalmoscopy and tonometry JAM

  29. Intermediate Ophthalmological Service 92002 / 92012 • Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient • 7 or less elements JAM

  30. 2004 New HCPCS Codes • “S” codes are useful for some private insurers • Medicare and other federal payers do not recognize them • They are useful when CPT does not have a code to accurately describe the service (i.e. LASIK, PTK, PRK, corneal topography) or for invoicing self-pay patients. • They specifically describe “routine exams” including refractions and permit a different charge JAM

  31. HCPCS “S” Codes • S0592 Complicated contact lens evaluation • S0620 Routine ophthalmologic exam including refraction; new patient • S0621 Routine ophthalmologic exam including refraction; established patient JAM

  32. 2006 Medicare Fee Schedule Office Visits • 99201 $34.23- 99211 $19.96- • 99202 $60.83- 99212 $35.96- • 99203 $90.58- 99213 $49.10- • 99204 $128.26- 99214 $77.08- • 99205 $163.20- 99215 $112.36- • 92002 $66.03- 92012 $60.50- • 92004 $120.51- 92014 $89.53- JAM

  33. 2006 Medicare Fee Schedule Consultations • 99241 $46.96- • 99242 $86.00- • 99243 $114.67- • 99244 $162.01- • 99245 $209.65- JAM

  34. Refraction 92015 • Non-covered service • Can be billed to beneficiary • failure to do so results in lost revenues • Reminders • Charge only for “Rx-able” refractions • Do not forget to charge for the final refraction when changing spectacles in a post-operative cataract patient JAM

  35. Gonioscopy 92020 • Bilateral • Requires documentation • describe visible angle structures • No limitations to diagnostic groups in most states • Fee $23.12- / $25.47 JAM

  36. Visual Field 9208x • Bilateral • Requires Interpretation • separate report form • narrative in body of medical record, on date of service • Fee $44.77- (-81) / $46.18 • Fee $58.29- (-82) / $59.09 • Fee $66.96- (-83) / $68.17 JAM

  37. Oculus Easy Field Perimeter • Screening AND Threshold fields • Color LCD-Display • Fixation monitoring • CCD camera • Stores up to 40,000 exams • Built-in printer

  38. Extended Ophthalmoscopy 92225 / 92226 • Unilateral • Initial (-225) vs. Subsequent (-226) • Implies detailed, extra ophthalmoscopy • document fundus lenses used • Modifiers RT /LT • Requires retinal drawings & interpretation • sizes, colors and dimensions carrier specific • Fee 92225 ($20.38-/$21.69) 92226 ($18.61-/$19.53) JAM

  39. Fundus Photography 92250 • Bilateral • Not Bundled • Requires Interpretation • Fee $65.86-/$69.46 JAM

  40. Fundus Retinal Photos ROI • Synemed (Canon 8+MP) • Cost $22,500.00 • Lease $500.00 • Breakeven 2 photos / wk • 8-10 MP digital non-mydriatic • 10 images / wk – lease = $22,273.20 annual revenue

  41. 2006 New ICD-9 Codes • Must report with 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 – 362.07 JAM

  42. External Ocular Photography 92285 • Report for documentation of medical progress • Ex.: close-up photography, slit lamp photography, goniophotography, stereo-photography • Bilateral • Not Bundled • Requires Interpretation and report • Fee $39.77-/$42.12 JAM

  43. RPS AdenoDetector 87809 • Bilateral • Infectious agent detection by immunoassay with direct observation, not otherwise specified • Modifier: QW for CLIA waived products • ICD-9 Positive test result • 077.3 other adenoviral conjunctivitis; acute follicular conj • 077.99 other diseases of conjunctiva due to viruses • ICD-9 Negative test result • 372.02 Acute follicular conjunctivitis, excludes EKC, PCF • 372.05 Acute atopic conjunctivitis • Fee $16.76 JAM

  44. Serial Tonometry 92100 • Bilateral • Requires Interpretation & Report • Example: Angle closure glaucoma • multiple measurements over time • Fee $76.05-/80.60 JAM

  45. Scanning Computerized Ophthalmic Diagnostic Imaging 92135 • Unilateral • Applies to glaucoma and retinal evaluations • Heidelberg / Heidelberg Retinal Topography (HRT III) • Carl Zeiss / Optical Coherence Tomography (OCT) • Carl Zeiss / Laser Diagnostic Technology (GDX) • Marco / Retinal Thickness Analyzer (RTA) • Optovue / RTVue • Requires Interpretation & report • Fee $38.91-/$40.64 JAM

  46. Scanning Laser Covered Diagnosis List • 362.85 retinal nerve fiber bundle defects 377.00-377.04 • 364.22 glaucomatocyclitic crisis Papilledema • 364.53 pigmentary iris degeneration • 364.73 goniosynechiae • 364.74 pupillary membranes • 364.77 recession of the angle • 365.00-365.9 glaucoma • 368.40-368.45 visual field defects • 377.9 unspecified disorder of optic nerve or pathways JAM

  47. Scanning Laser 92135 • Moderate Damage - payable once or twice per year, not with a field • Visual field examples • moderate reduction in retinal sensitivity • temporal wedge • Optic Nerve examples • enlarged cup with sloped or pale rim • focal notch • rim/disc >0.1 but <0.2 • prominent lamina cribrosa JAM

  48. Scanning Laser 92135 • Advanced Damage - rarely payable, fields more valuable • Visual field examples • loss of central vision • temporal island remains • severe reduction in retinal sensitivity • absolute defects to within 3 degrees of fixation • Optic Nerve examples • rim destroyed • rim/disc ratio<0.1 JAM

  49. Pachymetry 76514 • Bilateral • Measurement of central corneal thickness (CCT) proven by Ocular Hypertension Treatment Study (OHTS) to be standard of care in diagnosis and management of glaucoma, glaucoma suspect and ocular hypertension • Also billable for keratoconus, corneal transplants, cataracts with corneal dystrophies, guttata, edema • Requires Interpretation & Report • Fee $11.18-/$11.42 JAM

  50. Reichert IOPac • Portable • Battery operated • Stores up to 1000 pts. • USB and infrared interface • Down load to PC and printer • Detachable probe • Easily replaced if necessary • 888 849 8955

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