Coding Bulletin
January 2010
In This Issue
Sue’s View: Coding Competencies – Coding Mistakes You Should Never Make
Self assessment: one of my favorite things to do and what better month to begin than the first month of a new year. I’ve identified a few core coding competencies every physician, administrator, biller and coder should know. So test yourself and then your entire team. Answers can be found at the conclusion of the newsletter.
- Which is true when removing sutures?
a. Code as a corneal foreign body.
b. It is always part of the global surgical procedure.
c. If not the surgeon, or if outside the global period, bill the appropriate level of exam.
d. Both b and c
- Which of the following level of exams require dilation?
a. 92002 and 92004
b. 99204 and 99205
c. 99214 and 99215
d. Dilation is not a requirement of any level of exam.
- When performing a pterygium excision with amniotic membrane graft, which is correct?
a. Code for the pterygium with graft only. The amniotic graft is bundled in CCI.
b. Code for the amniotic graft only as it has the highest allowable.
c. Unbundle the two codes by appending modifier -59.
- CPT code 92235 fluorescein angiography and CPT code 92250 fundus photography are performed the same day. There is pathology in both eyes.
a. 92250-50 and 92235-50
b. 92250 and 92235 –RT and 92235 –LT
c. 92250 and 92235-RT and 92235-LT-50
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What’s Up with Consult Coding?
Certainly one of the biggest change of the New Year affecting ophthalmology is the decision by the Centers for Medicare and Medicaid Services (CMS) to eliminate consultation codes in the office and inpatient hospital setting. The CPT codes involved are 99241, 99242, 99243, 99244, 99245 and 99251, 99252, 99253, 99254, and 99255.
Why? The reason is due primarily to the definition of what actually constitutes a consultation versus a transfer of care. Despite Medicare’s attempts at clarifying the requirements, focus medical review (FMR) and comprehensive error rate testing (CERT) audits continue to show that according to CMS physicians continue to code a consult for what the payer determines is a transfer of care.
What? So what should physicians code in place of the office based consultation codes? If the patient is new to the practice, Evaluation and Management (E&M) codes 99201, 99202, 99203, 99204, and 99205 are the answer. If the patient is established (one who has seen a physician of the practice within the past three years) then E&M codes 99211, 99212, 99213, 99214, and 99215 are appropriate. Ophthalmologists may also choose any of the Eye codes 92002, 92004, 92012, and 92014 as well.
Physicians who perform an initial inpatient evaluation should bill the initial hospital care codes 99221, 99222, and 99223. For nursing facility care, E&M codes 99304, 99305, and 99306 should be used. As a result, multiple billing in initial hospital and nursing home visits could occur even in a single day. To distinguish between the consulting physician and principal physician, CMS directs principal physicians to append modifier AI to the appropriate level of E&M code. Consulting physicians should only submit the appropriate level of E&M code without a modifier. Subsequent inpatient visit codes 99231, 99232, and 99233 remain in effect.
Where do the consultation dollars go? CMS increased the work relative value units for new and established E&M office visits as well as initial hospital and initial nursing facility visits. The work value of the postoperative visits of surgical codes also received an increase.
Who? This is a CMS/Medicare specific ruling and it is not currently known if private payers, including Medicare Advantage Plans (MA), will similarly respond.
Questions and Answers
Question: If the physician writes a letter to another physician, is there a way to get paid separately for producing the letter?
Answer: It will be part of the E&M or Eye code billed. No separate bill to the payer or the patient is appropriate.
Question: Now that we can't bill Medicare for consultations, we must use Eye codes or E&M codes. One of our optometrists refers a patient to one of our ophthalmologists with specialty training. If the visit qualifies for a comprehensive exam, would you use 92004 or 92014? The patient is not new to the practice, but is new to the specialist.
Answer: Either 92014 or the appropriate level of E&M code. The patient is an established patient of the practice.
Question: If CMS eliminates consultation codes, why is the information still in CPT?
Answer: CPT 2010 was published long before the Federal Register published the elimination of consultation codes. Also non-Medicare payers may still recognize this set of codes.
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2010 PQRI Implementation Guide Available
Visit www.aao.org/pqri to obtain the 2010 PQRI Implementation Guide (3.0MB). Answers to frequently asked questions about PQRI can also be accessed on the site.
For those that missed the Jan. 5 PQRI and E-Prescribing Update webinar, copies of the slides and an auto play-back of the course is available.
ICD-10 Information Available
While ICD-10 does not become effective until Oct. 1, 2013, offices can find out more about what ICD-10 and HIPAA 5010 are all about. Why the change is necessary, a closer look at ICD-10 specifics as well as receive answers to frequently asked questions by visiting www.aao.org/icd10.
Correct Coding Initiative 16.0
Minor changes to ophthalmology in this Jan. 1 update.
- CPT codes 64470 joint injection and 64475 joint injection with image guidance were deleted from every code in the Integumentary and Eye and Ocular Adnexa section because these two codes were deleted from CPT.
- CPT codes 64490 and 64993 replaced 64470 and 64475 and are now bundled with every code in the Integumentary and Eye and Ocular Adnexa sections of CPT as well as Category III codes 0191T and 0192T insertion of aqueous drainage device.
- CPT code 92540 nystagmus test is bundled with 92265 needle oculoelectromygraphy
To view CCI version 16.0 in its entirety, visit Coding Tools at http://www.aao.org/aaoesite/coding/
Ask the Expert: Intravitreal Injections and Anesthetic
Question: When the physician codes 67028 for the intravitreal injection, can we also charge for the injection to numb the site? The two codes are not bundled in CCI.
The Academy’s Heath Policy provides the following answer: The syringe and xylocaine are all ready built into payment for 67028. There is no way around the fact that this is double billing. The guidance for anesthesia in the surgical CPT indicates that this anesthesia service is always included with the surgery/procedure.
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CMS Updates:
January is National Glaucoma Awareness Month
The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare provides coverage of a comprehensive annual glaucoma screening exam for Medicare beneficiaries at high risk for developing glaucoma.
Medicare provides coverage of an annual glaucoma screening for beneficiaries in at least one of the following high-risk groups:
- Individuals with diabetes mellitus
- Individuals with a family history of glaucoma
- African-Americans age 50 and older
- Hispanic-Americans age 65 and older
- A covered glaucoma screening includes both of the following:
- A dilated eye examination with an intraocular pressure (IOP) measurement
- A direct ophthalmoscopy examination or a slit-lamp biomicroscopic examination
What you can do? As a health care professional who provides care to seniors and others with Medicare, you can help protect the vision of your Medicare patients who may be at high risk for glaucoma by educating them about their risk factors and reminding them of the importance of getting an annual glaucoma screening exam.
Coding for Ozurdex Dexamethasone Intravitreal Implant
Effective June 18, 2009, the FDA granted approval for Ozurdex, a 0.7 mg intravitreal implant for the treatment of macular edema following branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO).
According to the package insert, effectiveness is based on less than 15 letter best-corrected visual acuity (BCVA) improvement. This improvement occurs within the first two months after implantation and the effects last one to three months after the onset of the improvement. Therefore Medicare would not expect to see a frequency of more than once a quarter. Patients without a documented response would not benefit from repeat implants.
To bill for Ozurdex™ services, submit the following codes:
- CPT code 67028 - Intravitreal injection of a pharmacologic agent (separate procedure) system
- HCPCS code J3490 – unclassified drugs for the Ozurdex implant
- QB field should be 1 unit
- Enter the following information in the comment/narrative note field:
Note: Until Medicare payers receive enough claims to determine a price, providers must submit an invoice copy for this drug.
Unprocessable Claims Detailed
To increase the number of your claims that successfully complete processing and enhance a positive cash flow, CMS is providing you with this helpful information.
The following is a listing of the top reasons Medicare Part B claims were returned as unprocessable claims (RUC)
CO 16 - Claim/service lacks information which is needed for adjudication. This could be:
- Referring name and UPIN required.
- Rendering physician number invalid or missing.
- Dates filed are not consistent.
- Facility zip code or state code invalid or missing.
- Invalid/incorrect ICD-9 code.
CO 24 - Charges are covered under a capitation agreement/managed care plan.
This denial usually means a beneficiary has a Medicare Advantage (MA) plan.
CO 140 - Patient/Insured health identification number and name do not match.
- Before submitting the claim, ensure you have a copy of the patient’s most recently issued Medicare card in order to compare the health insurance claims (HIC) number with the one you are submitting.
- Verify how the beneficiary’s name is listed on his/her Medicare card place it exactly that way on the claim. Do not use nicknames.
- On the Medicare card, verify which part(s) of Medicare the patient is eligible.
- Verify the beneficiary’s date of birth.
Answers to Coding Competencies Self Assessment
- d. Both b and c
- b. 99204 and 99205
- a. Code for the pterygium with graft only. The amniotic graft is bundled in CCI.
- b. 92250 and 92235 –RT and 92235 –LT
With my best wishes for a healthy and prosperous New Year!
Sue Vicchrilli, COT, OCS
Academy Coding Executive
