The Ultimate Compendium of Coding, Billing, and Documentation Advice For

Ophthalmologists and Optometrists 2018 Edition

The EyeCodingForum

Jeffrey P. Restuccio, CPC, COC

Medical Coding and Billing Consultant

Over 250 pages, Softbound

$225 updated every year

One-hundred coding, billing and documentation concepts every Eyecare professional “must know.”

Over a dozen CMS-1500 actual coding examples.

Tips and advice from over 20 years of teaching coding and billing as well as over 10,000 chart audits.

Suitable for any level, beginner to advanced. In addition to sound coding and billing information in this book the author shares hundreds of Gotchas! (Exceptions), Coding Tips, Notes, and gray areas you won’t find anywhere else.

Includes an Index

To Order select the ORDER tab on the EyeCodingForum website and select the manual option.

Main Sections:

1. The Very Basics: For those new to medical coding.

2. 60 Key Coding Concepts: This is an expanded version of what I include in my Optimizing Compliance/Maximizing Revenue Seminar. I call these “must know” concepts. Most are kept to one page with additional information later in the manual. More concepts are introduced in later sections.

3. Office Visits: This includes content from three one-hour Webinars: Office Visits, Scoring Medical Decision Making and Medical Necessity.

4. Diagnostic Procedures and Small Surgical Procedures: These are the most common Eyecare procedures performed in the office.

5. Revenue Cycle: This is a catch-all term for issues involving front-office and back-office operations. Some are not specifically coding or billing related but extremely important. I also include topics related to management that will useful to ambitious coders and billers.

6. ICD-10: This is the short version with an emphasis on new codes. I have over ten hours of recorded ICD-10 training for Eyecare. I may offer a separate ICD-10 training manual for Eyecare if there is enough demand.

7. More on HCPCS and Modifiers: For those wanting additional formal coding training.

8. Optimizing Compliance: This is from my two-part series on Coding Compliance for Eyecare.

9. Maximizing Revenue: These are my top tips for getting every penny you deserve! (and always assume compliantly.) Each topic begins with TIP$. If you want pay for this manual and are experienced, jump ahead and review this section early.

10. DME-MAC and Post-Cataract Glasses: This is a different animal from Part-B billing and coding and office visits and procedures Clinics either love or hate selling post-cataract glasses. I cover the basics and offer tips for making this a winner in your clinic.

11. Additional Information: Too good to leave out but more advanced I included this information for the very ambitious or those who work for large clinics.

Below is the Table of Contents from the manual. In the beginning we cover basics in a succinct manner, most on one page to ensure everyone has a firm foundation in concepts.. Further in the manual several topics are expanded. Key topics of focus include: office visits, vision plans, the routine vision exam, comparing and contrasting E & M codes versus the Medicine Section codes (920xx), diagnostic tests, compliance, maximizing revenue, and dozens of real-world tips and “gotchas.” Forward 5

Table of Contents 6

Introduction 15

A Little Bit about the Author 16

Legend of Terms 17

Manual Organization 18

The Very Basics for Newbies 21

Different Types Of Healthcare Plans 21

The CMS-1500 Form 22

More Basic information 24

What is a Valid Source? 24

Over 60 Key Coding Concepts 25

Ranking of Guidelines 26

Clinical Resources 28

CPT© Codes 29

HCPCS codes 30

Modifiers 32

Small Surgical Procedures 33

Modifier 25 33

ICD-10 Codes 35

What is a Screening? 36

What is a Routine Vision Exam? 37

Long-Term Use of a High-Risk Drug 38

Office Visits 39

New versus Established Patients 39

920x2 Documentation Issues 40

920x4 Documentation Issues 40

Diagnostic Tests 41

Medical Necessity 42

Surgical Operative Reports 43

Co-Management 44

MOD-24: Unrelated E & M Service by the Same Physician during a Postoperative Period 45

NCCI Edits 46

Cloned Notes 47

Miscellaneous and Unlisted CPT™ codes 47

Software for Eyecare 48

Place of Service (POS) Codes48

Medicare and Medicare Guidelines 49

Medicare Jurisdictions 2017 Diagram 50

Medicare Jurisdictions 50

Medical Local Coverage Determinations 51

Incident-To Services (E & M Code 99211) 52

Medicare Modifier - GA 53

Medicare Modifier -GY 53

What is Medicare Advantage (MA)? 54

Medicaid 55

Vision Plans 55

Private Medical Insurance 57

Third-Party Administrator and Self-Funded Plans 57

Carrier-Specific Rules 58

Carrier-Specific Manual 58

Self-Pay Patients 59

What is a SOAP Note? 60

SNOCAMP 61

1997 versus 1995 Exam Guidelines 62

Counseling and Coordination of Care, Time 63

History: Chief Complaint (CC) 64

History of Present Illness (HPI) 65

Review of Systems (ROS) 65

Past, Family, Social History (PFSH): 67

E & M Levels 68

E & M Code Exam Elements 69

E & M: 2 of 3 Rule/3 of 3 Rule 70

Medical Decision Making (MDM) 71

Upcoding/Downcoding 72

CPT™ Category II Codes 75

CPT™ Category III Codes 77

Medicare PFSRVU Database 79

Relative Value Units (RVU’s) 79

Medicare Conversion Factor 79

More on RVUs 80

Bilateral Surgery Modifier 80

Global Period 81

Professional Component (MOD-26) 82

Technical Component (MOD-TC) 82

Interpretation and Report 83

What Exactly is a Red Flag? 84

Credentialing 87

HIPAA 87

MACRA/MIPS 90

Timely Filing Period 91

Legal Issues 92

Office Visits 93

Rules for Office Visit Documentation 93

Exam: Miscellaneous Notes 93

Diagnosis Problem Lists 94

Using MDM Table B: Data Reviewed 95

Medical Necessity and Office Visits 96

Medical Necessity Plan for Action 107

Diagnostic/Surgical Procedures for Eyecare 109

Bilateral Procedures 109

Global Periods 110

Reporting Diagnostic Procedures with an Office Visit on the same DOS 110

Gonioscopy 111

Corneal Topography 112

Angiography Codes 112

Serial Tonometry 113

Bandage Contact Lenses 113

Fundus Photography (92250) 115

Extended ophthalmoscopy (92225 and 92226) 115

OCT, GDX HRT, SCODI 116

External Ocular Photography 119

INTACS™ 119

Visual Field Exam codes 120

Corneal Pachymetry (76514) 120

Punctal Plugs 121

Epilation – Removal of an eyelash 122

Excision of a chalazion 123

More Coding and Billing Tips 124

Eyecare Surgical Procedures 125

Coding for Removing Rust Rings 126

Ophthalmologists Only 127

The Surgical Package 129

Minor Foreign Body removal Codes 130

IOL Master and Optical Coherence Biometry 131

Coding Compliance 135

The Mind of an Auditor 135

Types of Audits 136

Fraud and Abuse 136

The 50% (Auditing) rule 137

Seven Core Elements of a Compliance Plan 137

Compliance Checklist 138

Specific Audit Focus Examples 138

Documentation Consistency 138

Medical Records Tips 140

More on Cloned Notes 141

Common Office Visit Errors 142

What is a foreign body? 142

Glaucoma Suspect vs Probable Glaucoma 142

Dilation Contra-indications, Refusal, and Substitutions 143

Compliance Obstacles to Implementation 143

Top Gray areas in Eyecare Auditing 144

Maximizing Revenue Tips 147

TIP$: Do you sell supplements for ARMD? 147

TIP$: Special Codes 147

TIP$: Consultation Codes 148

TIP$: Linking Refraction Code 92015 to a Medical Diagnosis 149

TIP$: The Three Stable Conditions Rule 150

TIP$: Carrier Tips and Tricks 150

TIP$: Learn how to ask the question correctly 151

TIP$: Denial Management and Appeals 153

TIP$ Top Ten Medicare Part-B Denials (all specialties) 153

TIP$: “Casino” Health Insurance 154

TIP$: Twelve Appeal Steps 155

TIP$: Appeals Process (Medicare) 155

TIP$: Utilization Reviews 156

TIP$: National Specialty-Specific Manuals 157

TIP$: Maximizing Reimbursement Three Specific Eyecare Examples 158

TIP$: Setting Fees 159

TIP$: Additional Drugs with Adverse Affects 160

TIP$: Post Cataract Glasses billed to the DME-MAC 161

TIP$: Out of the Box Revenue Opportunities (for Optometrists) 162

TIP$: Other Place of Service (POS) Codes 162

TIP$: Correctional Facilities: Resources 163

TIP$: Vision Therapy Services 164

TIP$: Low Vision Services 164

TIP$: Eyecare Marketing: Ways to Impress 165

TIP$: Visual Evoked Potential 166

TIP$: Dual-Diagnosis Children Scenario 167

TIP$: Telemedicine and Eyecare 168

Revenue Cycle 169

Front Office Operations 169

Back Office Operations 169

Explanation of Benefits (EOB) 169

Coordination of Benefits (Care) (COB) 169

Crossover Claim 169

Write-Offs 170

Balance Billing 170

2018 ICD-10 Updates For Eyecare 171

ICD-10 Coding Highlights 180

The Big Picture 184

The AHA 2018 ICD-10 Coding Guidelines 188

ICD-10 Coding Specificity Example 188

ICD-10 Coding for Eyecare 190

Glaucoma Stages 190

DME-MAC Post cataract glasses 193

Marketing DME-MAC services 194

Post-Cataract Glasses Rules 195

Medically Necessary Options 196

Filing the Claim 198

Billing Example 198

Most Common DME-MAC Errors 201

Additional Information 205

CPT™ Modifiers 205

The 2015 “X” Modifiers 205

MOD-22 206

MOD-25 206

MOD-32: Mandated Services (rare) 207

MOD-50: Bilateral Procedures 208

MOD-52: Reduced Service 208

MOD-53: Discontinued Procedure 209

MOD-54, 55 & 56 209

MOD-57: Decision for Surgery 210

Mod-58 210

Mod -59: Distinct Procedural Service211

Surgical CPT™ Modifiers 211

Mod -62: Two Surgeons 211

MOD-66: Surgical Team 211

Mod-76 and 77 212

Mod -78: Return to the Operating Room 212

Mod -79: Unrelated Procedure 212

Mod -81: Minimum Assistant Surgeon 213

Mod -82: Assistant Surgeon 213

Mod -99: Multiple Modifiers 213

Resources For the Truly Dedicated 214

Searching for Information on the Internet 215

Conclusion 217

Coding and Billing for Eyecare Manual Index 218

Selected Sections:

What is a Screening?

There are actually four different types or definitions of “a screening.”

1. Any procedure performed in the absence of a diagnosis supporting medical necessity. The most common examples of diagnostic services performed as a screening include:

a. Fundus photography.

b. Pachymetry

c. External Photos

Always link a Routine Vision Exam (920xx code) to Z01.00 or Z01.01 if there is no presenting problem (and no medical codes to link to it.)

2. Specific screening codes

The two Medicare G HCPCS codes for glaucoma are specific screening codes. Medicare should pay on these two codes

G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist

G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

Real World: Most clinics do not report these codes in actual practice. The main reason is that most Medicare-age patients will have a presenting problem that will support an office visit code.

3. An office visit and associated diagnostic tests linked to the screening for the long-term use of a high-risk drug like Plaquenil (for Rheumatoid arthritis), ICD-10 code: Z79.899. These should be always reimbursed by private medical, Medicare, and Medicaid. If not reimbursed I would appeal.

4. A Routine Vision Exam is a comprehensive eye exam for pathology (not a refraction exam) without a presenting problem or chief complaint. It is linked to the Z01.0- code. It is also called an annual exam or a well exam. The key is that it is a screening.

The concept that connects all of these is that there is no presenting problem. The chief complaint should be documented as a screening or Routine Vision Exam. Some screenings are reimbursed and others are not depending on type and carrier.

Gotcha! Refraction problems (anything H52.–) are not presenting problems. They should only be linked to 92015 and only paid as a refraction benefit (mostly Vision Plans).

WDIC? Screenings pose both an opportunity and a challenge–particularly for Optometrists. You must know which ones are paid and which ones are not. Not understanding the specific requirements for coding and reporting could cause denials.

What is a Routine Vision Exam?

As just explained, it’s considered a screening–but it is also more than that. There is no specific CPT™ Code for a routine eye exam. Most providers use 92014 because routine exams are overwhelmingly reported to a Vision Plan and not a Medical Plan (but there are exceptions). Even medical plans with a refraction benefit typically sub-contract the refraction portion to a Vision Plan such as VSP, EyeMed, Davis Vision, or Spectera.

Coding Tip: Always link your routine vision exam CPT™ code to ICD-10 codes Z01.00 or Z01.01, not a refraction code.

Coding Tip: A Routine Vision Exam is not a refraction exam! Technically a refraction exam is not included in a routine vision exam (although the majority of Vision Plans combine them into one payment). Most of your patients think of them as one service but they are not. They are two separate and discrete services.

Gotcha! Occasionally you will see an Eyecare coding article offering the two routine eye exam “S” codes below as an option. Only report these if the specific plan requires them. Otherwise do not report them. They are vague and poorly defined.

S0620: Routine ophthalmological examination including refraction; new patient

S0621: Routine ophthalmological examination including refraction; established patient

Always explain your patients that a Routine Vision Exam is a comprehensive exam for pathology (screening for a medical problem). It can include up to 14 exam elements. I repeat: it is not a refraction exam; that’s separate.

There are no universal Routine Vision requirements for dilation. It may be required per your Vision Plan contract. The state of Florida requires all new patients receive a dilated fundus exam. That is a state regulation.

Coding Tip: There is no national guideline or definition of what elements are included in a routine vision exam. This varies by state and school. Also your carrier contract could state what is required.

Gotcha! The word “routine” is no longer part of the ICD-10 code description.

Gotcha! Vision Plans don’t have to follow CPT™ or Medicare rules and guidelines!

Real World: It’s worth repeating that certain carriers, in particular Vision Plans and local Medicaid’s–make up their own rules. If they combine both the refraction exam and the routine vision exam into one code and make it one service, they can do that–even if it’s technically not accurate.

WDIC? Explaining what your comprehensive exam includes will help you compete with discount Eyecare clinics. This is confusing for the providers, staff, and the patients.

Medical Necessity

There are actually two definitions and applications:

1) Billing/CPT™ Codes: The most common definition is related to billing. Medical necessity is the one-to-one linking of a diagnosis to a CPT™ code to support reimbursement by the medical carrier. Some CPT™ codes are reimbursed on only a very specific diagnosis. Some CPT™ codes require two diagnoses (e.g., long-term use of a high risk drug).

The number one source for medical necessity information is the Local Coverage Determination available from your Medicare carrier. Private insurance companies sometimes will have bulletins with a list of ICD-10 codes that support medical necessity. This information is not in the CPT™ or ICD-10 manuals. It is strictly related to reimbursement by a carrier. Without documentation supporting medical necessity, the procedure is considered a screening and most medical plans will not reimburse the service.

Gotcha! Medical Necessity is the “Catch 22” of healthcare. You are only paid if you find a condition supporting medical necessity; but you may not know unless you perform the diagnostic test. Clinicians hate this.

If you suspect a lesion on the peripheral retina you may want to perform fundus photography to obtain an image and confirm. If you don’t find anything then the service is considered a screening and not reimbursable. But you won’t know unless you perform the service!

The best advice is to have the patient fill out an Advanced Beneficiary Notice (ABN) or similar form for a non-Medicare patient. The form must state they are responsible if the carrier does not pay and they understand they can refuse the service.

2) Office Visits: Medical necessity also refers to supporting the level and frequency of an office visit.

Coding Tip: Remember, that Vision Plans don’t care; they don’t require a presenting problem; there is no requirement for medical necessity. That’s the nature of a Routine Vision Exam. We will cover in more detail the Chief Complaint and the nature of the Presenting Problem later in this manual.

Gotcha! Refraction codes (H52.--) do not support a Routine Vision Exam (often reported with 92014) even though most all Vision Plans and a few medical plans may reimburse. Refraction codes have nothing to do with a 92014 code or any 920xx code. Link refraction codes only to 92015, refraction services.

The Ultimate Compendium of Coding, Billing, and Documentation Advice for Ophthalmologists and Optometrists: 2018 Edition includes 125 test questions to reinforce learning. Below are 25 questions from the manual. 1) With the advent of ICD-10, state Worker’s Compensation Boards:

Answer 1: All decided to stay with ICD-9. Answer 2: Had an option of adopting ICD-10 on the Oct 1 2015 date or continue with ICD-9. Answer 3: Were mandated to adopt ICD-10 on Oct. 1 2015 just like Medicare, Medicaid and all private insurance carriers. Answer 4: None of the statements above are correct. 2) Where and what is the uvea of the eye?

Answer 1: It includes three contiguous structures: the iris, ciliary body, and the choroid. Answer 2: It is a ring of fibrous strands that connects the ciliary body with the crystalline lens of the eye. Answer 3: It is in the posterior segment Answer 4: None of the Answers are Correct. 3) The AMA CPT Assistant is:

Answer 1: Is a widely acclaimed certification title. Answer 2: A valuable coding resource. Answer 3: Applies only to primary care. Answer 4: None of the Answers are Correct. 4) What is a drawback of an HMO?

Answer 1: Providers have an incentive to keep treatment costs at a minimum. Answer 2: The HMO administrators determine what services are reimbursed and what is not. Answer 3: The provider is now a gatekeeper to the patient's medical care. Answer 4: All of the Answers are Correct. 8) If Medicare guidelines don't agree with AMA CPT Guidelines, which one do you go with?

Answer 1: Medicare Answer 2: AMA CPT Guidelines Answer 3: Neither Answer 4: Go with whichever agrees with the state Medicaid Guidelines

9) Eye exam codes S0620 and S0621:

Answer 1: May be used for self-pay patients Answer 2: Are used by some Medicaid carriers Answer 3: Are used for new or established routine office visits and include refraction.

Answer 4: All of the Answers are Correct. 10) Which of the following is NOT descriptive of HCPCS G codes?

Answer 1: They are temporary codes. Answer 2: They are assigned by CMS. Answer 3: They are under review by the AMA for CPT inclusion. Answer 4: They include durable medical equipment (DME). 11) When should you use CPT code 99070?

Answer 1: CPT states this code should be used for all supplies. Answer 2: Only use this code for Medicare Answer 3: Only use this code for Vision Plans. Answer 4: Only if a carrier requires its use in writing.

12) Modifiers E1 through E4 describe what?

Answer 1: Nothing to do with the eye. Answer 2: Denote which eyelid, upper or lower and right or left. Answer 3: Denote which and what part of the eyeball. Answer 4: Describe the level of impairment for cataract cases. 13) How is modifier 25 used?

Answer 1: Use it to report the professional component only. Answer 2: Use it to report unusual anesthesia (in the office). Answer 3: When a small surgical office procedure and an Evaluation and Management (E & M) code are reported on the same Day of Service

Answer 4: None of the Answers are Correct. 14) How is a chemical burn of the cornea reported in ICD-10?

Answer 1: Use the ICD-10 burn codes: T26.1-x-. Add laterality and occurrence character. Answer 2: Use the ICD-10 corrosion codes T26.6-X- Answer 3: There is no specific code for a chemical burn. Answer 4: Report it as a foreign body using the T15.--X- codes.

15) Specific ICD-10 codes for pterygium include options for nasal and temporal?

Answer 1: TRUE Answer 2: FALSE Answer 3:

Answer 4:

16) Screenings are never paid because there is no presenting problem.

Answer 1: TRUE Answer 2: FALSE Answer 3:

Answer 4:

17) An adverse effect can be from:

Answer 1: A correct substance taken in the wrong amount. Answer 2: A substance not normally ingested. Answer 3: A correct substance taken in the correct amount. Answer 4: Any accident, injury, or poisoning. 18) What type of office visit would not support any 920x2 encounter?

Answer 1: A resolved-problem follow-up encounter. Answer 2: A new patient. Answer 3: A routine eye exam. Answer 4: A new diagnosis. 19) The 920x4 comprehensive exam:

Answer 1: Requires dilation, EOM, CF, and the initiation of something. Answer 2: Requires external ocular adnexa, EOM, CF, and the initiation of something.

Answer 3: Requires dilation, EOM, CF, and external ocular adnexa. Answer 4: Requires dilation, external ocular adnexa, EOM, CF, and a new diagnosis.

20) Medical necessity information is found in:

Answer 1: The ICD-10 manual Answer 2: The CPT manual Answer 3: HCPCS manual Answer 4: None of the Answers are Correct.

21) What are NCCI edits and what is their significance?

Answer 1: National Correct Coding Initiative; edits not found in the CPT manual. Answer 2: National Correct Claims Initiative; Linking of CPT codes to the ICD-10 codes. Answer 3: National Correct Coding Initiative; these guidelines are in the CPT

Answer 4: These are age and sex edits for claims submission. 22) What is the rule for using an E&M code versus using a 992xx Exam code?

Answer 1: Always use an E & M code for a medical diagnosis. Answer 2: Always use a 920xx Exam code when the eyes are dilated. Answer 3: Always use a Level 5 E & M code when you report all 14 Exam

Answer 4: Use the code and level that is supported by the documentation. 23) When is time a key factor when assigning a level to an E & M Code?

Answer 1: Never Answer 2: Time is always a factor Answer 3: Time is a factor only when counseling or Coordination of Care dominates the encounter.. Answer 4: The three Key factors are Time, Exam and History for an office visit. 24) What is the 2 of 3 rule?

Answer 1: This is an E & M guideline stating that for an established patient only two of the three key components (history, exam, and medical decision making) are required to be at the reported level. Answer 2: If 2 of 3 doctors report the service that way then the insurance company will accept it. Answer 3: if three services are provided on the same day of service the insurance company will only pay for two. Answer 4: None of the Answers are Correct. 25) Can the optometrist substitute a visual field exam for a confrontation field (as an Exam element) ?

Answer 1: Yes Answer 2: While many providers consider the visual field exam a better test, there are currently no Medicare guidelines stating this can be done. Answer 3: No Answer 4: Currently about half of the Medicare carriers allow it.