WELCOME to the OPW
EyeCare Benefits INSURANCE
OVERVIEW Seminar
HOSTED BY OPW
&
OPW EYECARE BENEFITS COMMITTEE
Dr. Glen Owen, Dr. Mark Michael
Dr, Ivan Hyde
PRESENTERS
• Dr. Ken White
OPW insurance liaison
• Judy White
Billing and coding consultant
AUDITS AUDITS AUDITS
• Because you are being paid doesn’t mean
you are doing it right?
• RAC’S (4.1 Billion recovered 2011)
• Examples
– $12000 Overpayment by payor
– $5000 (DSHS dispensing fees)
– Recourses available
PAYORS CONSIDER
THESE ITEMS FRAUD
Billing for: Services Not Rendered--“Phantom Billing” (or not documented in chart )
Services Performed by Non-Licensed or
Non-Payable Practitioners (Staff initialed procedures, but
no order from doctor)
A More Costly Service than Provided--“Up-Coding’ (Not medically necessary)
PAYORS LIST OF FRAUDULENT ITEMS
(Premera)
•
“As with all small percent of providers we look at there is potential for up-coding and
unbundling”·
– Up-coding new and established codes to comprehensive when the
documentation does not support this level
– Unbundling services that are included in a comprehensive
examination and billing these in addition.
– One of the bigger issues we see is practitioners attempting to
manipulate the sunglasses exclusion benefit by attempting to pass
these off as “tinted” lenses. Most vision benefits exclude
sunglasses and non rx lenses.
– Billing for services not rendered. Unless there is a chart audit
payable codes will go through the system without documentation
requirements.
– Manipulating the diagnosis codes so vision pays under medical
when the member has no vision benefit or a “richer” medical
benefit than vision.
PAYORS LIST OF FRAUDULENT ITEMS
(DSHS)
1. Follow the rules and/or billing instructions:
Read them carefully, keep current and follow
them.
2. Document, document, document!
3. Make sure that documentation is clear, legible
and supports the service billed and remember;
If it’s not documented in the chart, it didn’t
happen and if it didn’t happen, payment will be
recouped.
MEDICARE 2012
• Social Security began in 1937
• “Elderly National Health Insurance” began
in 1966 (Prelude to Medicare)
• Optometry included in Medicare in 1987
• CMS is the largest insurance company in
the world
• Estimated by 2015 over 25% of OD billing
will be Medicare
MEDICARE 2012
• 65 and older
• Under 65 with certain disabilities
• All ages with end stage renal disease
MEDICARE 2012
• PART A
– Inpatient care in hospital
– Skilled nursing facilities
– Home Health Care
MEDICARE 2012
• PART B
– Dr Services, Outpatient Care, DMEPOS
and some Preventative Services
– Subscriber Deductible $140.00/yr
– Subscriber Premium $99.90/mo
• Higher Income beneficiaries pay as much as
$319.70/mo
MEDICARE 2012
• PART C
– Run by Medicare approved private
companies
– Includes Part A, Part B and sometimes
Part D
– Began January 2006, formally called
Medicare Choice Plans
MEDICARE 2012
• PART D
– Prescription drugs
– Began January 1st 2006
– Medicare mess!!!
MEDICARE 2012
• ORIGINAL MEDICARE
– Run by federal government
– Covers Part A and Part B
– Beneficiary can purchase a supplement to
cover deductible and 20%
– Can purchase Part D (Drug coverage)
separately
MEDICARE 2012
• MEDICARE ADVANTAGE PLANS
(PART C)
– Advantage Plans in Washington State
• 17 plans 2006, (Mostly Fee For Service)
• 210 plans 2008
• 157 plans 2010
• 15 carriers 2012
– FFS = 2 PPO = 5 HMO = 13
MEDICARE 2012
• MEDICARE ADVANTAGE PLANS
(PART C)
– Private companies approved by Medicare
– Covers Parts A & B and sometimes D
– May charge different amounts for items and
services
– Usually charges additional monthly premium
– Never has supplement
– Always send claims to plan
MEDICARE 2012
• MEDICARE ADVANTAGE PLANS
(PART C)
– 5 types of plans
• PPO (Preferred Provider Organization) IE. Regence
• HMO (Health Maintenance Organization) IE. Sound
Path Health & Spokane Community Care
• FFS (Fee for Service) IE. Sterling
• SNP (Special Needs Plan) IE. Molina
• HMOPOS (Health Maint. Org. Point of Service) IE.
Community Health First
MEDICARE 2012
• Medicare contracting reform
– New Jurisdiction
• 10 Western States – Jurisdiction F
• Noridian retains contract
DMEPOS
• Washington is Jurisdiction D (Part B
supplies)
• Includes 17 western states
• Noridian contract = past 11 years
MEDICARE
• WHAT ARE THE DIFFERENCES?
1. Enrolled
 Has a signed contract with Medicare that physician bills
Medicare for beneficiary and accepts their rules for
medically necessary ophthalmic goods.
Enroll at
https://www.noridianmedicare.com/dme/enroll/
2. Non-Enrolled
 No DME signed contract with Medicare. Cannot see
Medicare patients for medically necessary ophthalmic goods.
3.
Opt-Out
 Signed opt-out affidavit filed with Medicare
 Signed private contract with each Medicare patient for care
 Applies to both Part B services and DMEPOS items
MEDICARE
Two Choices If Enrolled
1. PARTICIPATING (accept assignment)
– Physician sends CMS billing to Medicare
– Medicare pays physician allowed Medicare fees at
80%
2. NON-PARTICIPATING
–
–
–
–
Physician sends CMS billing to Medicare
Maximum 115% of allowed Medicare Fees
Patient pays physician U&C fees for DMEPOS
Medicare pays patient allowed Medicare fees at
80%
DMEPOS
Enrollment fees $ 523.00
1. New location
2. Additional locations
3. Change of ownership
4. New tax ID #
5. Reactivations
6. Re-validation (Every three years)
Fees must be submitted through internet based
PECOS system
DMEPOS surety bonds
1.
2.
3.
4.
5.
Mandatory for DMEPOS enrolled providers that fill
outside scripts
Effective 05/04/2009
$50,000.00 Bond / location
Cost: $1500-2000 / yr
Mandatory for participating and non-participating
Verify script and make it your own to avoid bond
Government approved bond carriers are mandatory
www.fms.treas.gov/c570/c570_a-z.html
MANDATORY CLAIM FILING
• Effective September 1st 1990, Claim Filing
Mandatory – Social Security Act 1848(g)(4)
• Law applies to all suppliers providing covered
services or items to Medicare beneficiaries
regardless of supplier status
• The fact that the provider has not acquired a
Medicare billing number or closed a billing
account offers no protection from this requirement
• Does not apply to non-covered services, due to
statutory exclusion unless beneficiary requests
submission - IE. refraction
MANDATORY CLAIM FILING
• Law prohibits supplier from charging
beneficiary for claim submissions
• Non-compliance with this law may result in
a $2000.00 fine for violation
• Medicare claims must now be submitted
within 12 months
PECOS, what’s it all about?
• All providers must be listed in PECOS to provide
some services, post-op care, some screening tests
and scripts for post-op glasses
• To be listed in PECOS provider must have
enrolled or submitted changes to Medicare
enrollment after Nov 2003
PECOS
 To find if you are listed as an enrollee in
PECOS, go to the following CMS Website.
http://www.cms.gov/MedicareProviderSupEnroll/04
_InternetbasedPECOS.asp#TopOfPage
 To enroll in the PECOS system go to:
https://PECOS.CMS.hhs.gov
MEDICARE POST OP
BILLING
• CATARACT AND YAG SURGERY
– 90 DAY POST OP PERIOD
• Use modifier 24 with E&M code if seen for
totally unrelated problem during post-op
• Use modifier 79 if treating second eye post
op during first eye post op 90 day period
– IE. 66984-55-79-RT or LT
MEDICARE POST OP BILLING
• Box 17 = Surgeon’s Name
• Box 17b = Surgeon’s NPI
• Box 19 = “Post op care from (date)* to (date)**”
– * Date of transfer on surgeon’s post op letter
– ** 90 days from date of surgery (day one is day after
surgery)
Calculation Website:
http://www.medicarenhic.com/providers/billi
ng/billing_calc_global_period.html
MEDICARE POST OP BILLING
• Box 21= Must use same ICD-9 code as surgeon uses
• Box 24a = Date of surgery
• Box 24d = CPT code must match surgeons
– Usually 69884
• Use modifier 55 & RT or LT for Post Op
– More complicated surgery will have different codes and
higher reimbursement amounts
PQRS,
Why should I participate?
• Applies to Medicare only (0.5% Bonus)
Must report three measures, 50% of the time
Only 3 dx’s to think about; AMD, POAG, DIABETES
• Penalties in 2015 (1.5%)
• Current Update for ODs Available at:
http://www.aoa.org/x17508.xml
eRx INFORMATION, WHAT
YOU NEED TO KNOW
AND WHY
• Do I have to participate in PQRS to participte
in eRx? (No)
• Separate from and in addition to Physician
Quality Reporting (PQRS)
• Is this a voluntary program?
– (Yes) (1% bonus2012)
• What if I don’t participate?
– (No Penalty for ODs 2012) (2013=?)
eRx
• What if I decide to participate?
– Applies to Medication; Not glasses rx
– Rx directly from your computer to pharmacy
– Helps to Eliminates fraud
• Do I have to have specific software? (Yes)
– Qualified System that will generate a complete
medication list that incorporates data from pharmacies
and provide information on lower cost, and
therapeutically appropriate alternatives
eRx , GETTING STARTED
• HOW DO I GET STARTED?
– Learn:
– http://www.aoa.org/x18599.xml
– http://www.aoa.org/x18962.xml
– Download AOA eRx Webinar;
http://www.aoa.org/x18392.xml#erx
– Get Started
http://www.getrxconnected.com/OPTOMETRIC/
site.aspx
– Free Software
http://www.nationalerx.com/prescribers.htm
2012 CHANGES
•
PREMERA
Corneal Topography (CPT 92025) has been eliminated
•
DSHS
Pediatric hardware only
• ASURIS MED-ADVANTAGE (Regence)
VSP FOR routine exams and hardware
(OCT) 2012 CHANGES
• 92132 Scanning computerized ophthalmic diagnostic
imaging, anterior segment, with interpretation and report,
unilateral or bilateral.
• 92133 Scanning computerized ophthalmic diagnostic
imaging, posterior segment, with interpretation and report,
unilateral or bilateral, optic nerve.
• 92134 Scanning computerized ophthalmic diagnostic
imaging, posterior segment, with interpretation and report,
unilateral or bilateral, retina
CPT 92070 has been deleted in 2012
• 92071 – Fitting of contact lens for treatment of
ocular surface disease (Per Lens)
• 92072 – Fitting of contact lens for management of
keratoconus, initial fitting (Per Lens)
• Neither code includes supply of lens and may be
reported as 99070 (supplies and materials provided
by physician over and above those usually included
with the office visit or other services rendered or;
• The appropriate HCPCS material code (V code) or S
code (S 0500 (disposable contact lens)
• Additional care (visits), use appropriate E&M
services or general ophthalmological services.
ADVANCE BENEFICIARY NOTICE OF
NONCOVERAGE
• New ABN form (03/11) Mandatory after 1-1-12
• Replaces old ABN and NEMB
• Used to inform patients that fees will probably
not be covered my Medicare
• Must be filled out and signed before materials are
ordered and rendered
• No “blanket” form to every Medicare patient
• One copy for patient and one in file for 7 years
ADVANCE BENEFICIARY NOTICE OF
NONCOVERAGE
• Use GA modifier when ABN is executed
• Mandatory field of cost estimate for
items/services
• Must be signed and dated by beneficiary or
authorized representative
• Includes beneficiary options
- Individual may choose to receive item/service
- Pay for it out-of-pocket
- No claim submitted to Medicare
BILLING DMEPOS
• Coverage Requirement
– Medically necessary to restore vision due to
surgical removal or congenital absence of
organic lens of the eye
– Covered diagnoses are limited to:
• Pseudophakia (V43.1)
• Aphakia (379.31)
• Congenital Aphakia (743.35)
– All other diagnosis will deny as non-covered
– Patient is eligible even if they had surgery prior
to Medicare coverage.
BILLING DMEPOS
• Pseudophakia
– Diagnosis code V43.1
– Only one pair of lenses & frames or contacts
are allowed after each cataract surgery
– If patient does not receive glasses or contacts
between two separate surgeries, only one pair of
lenses and frames or contacts are allowed.
– Frames are covered only when ordered with
lenses
– Replacements not covered
– No time limit after surgery to order materials
BILLING DMEPOS
• Aphakia
– Diagnosis code 379.31 or 743.35
– The following combination of frames, lenses or
contact lenses are allowed:
• Bifocal lenses in frame OR
• Lenses in frames for far vision and lenses in frame
for near vision OR
• Contact lenses worn the same time as eyeglasses and
eyeglasses when contacts are removed
• No limit on replacement except soft lenses
BILLING DMEPOS
• Contact Lenses
– V2520 -V2523
– Allowed fees include professional fitting fees
– No allowance for solutions
– Not eligible when used as corneal dressing
BILLING DMEPOS
• Frames
–V 2020 standard frame
– Use amount allowed by Medicare. 2012 =
$65.42 OR
– Use your retail (U&C) if less than Medicare
allowed amount
– V2025 delux frame
• Retail amount over Medicare allowed amount
BILLING DMEPOS
• Frames
– When billing for delux frame enter standard
frame code (V2020) on first claim line
– On second claim line, enter delux frame code
(V2025) and difference in charge between
standard and delux frame
– No ABN form or GA modifier
– No other modifiers
BILLING DMEPOS
• Medically Necessary Options
– Following options are covered if ordered by
physicians for medically necessary reasons:
• Photochromatic V2744 ( Glass or Plastic)
• Tint V2745
• Anti Reflective Coating V2750
• Oversize lenses V2780
• Polycarb lenses V2784 (Must have functional
vision in only one eye)
• Use KX modifier if medically necessary (rare)
• Must be documented by treating physician and
medical record
BILLING DMEPOS
• When the above options are patient
preference items, they must be billed on a
separate CMS form
– An ABN form must be executed
– Use GA EY Modifiers
– Will be denied as “not medically necessary”
BILLING DMEPOS
• UV Protection V2755
– UV protection reasonable and necessary
following cataract extraction. Additional
justification not necessary beyond inclusion on
the order
– Not medically necessary for polycarb lenses
– Only if coating is applied to lens, not as an
add-on for uv protection inherent in the lens
material
BILLING DMEPOS
• Progressive Lenses V2781
– Enter appropriate code for either bifocal
(V2200-V2299) or trifocal (V2300-V2399) on
the first claim line
– On second claim line, enter progressive lenses
V2781 and the difference in charge between
progressive and standard lenses
– ABN or GA modifier not required
– V2781 denied as patient responsibility
BILLING DMEPOS
• Non Covered Patient Preference Items
–
–
–
–
–
–
–
–
–
V2025 Delux Frames – Special billing rules apply
V2600-V2615 Low vision aids
V2756 Eyeglass case
V2760 Scratch Cote
V2761 Mirror Coating
V2762 Polarization
V2781 Progressive - Special billing rules apply
V2782 – V2783 High Index
V2786 Special occupational multifocal
BILLING DMEPOS
• Replacement lenses in frame
– Patients with dx of pseudophakia V43.41.
Statutory, one pair after each cataract surgery,
no replacements
– Patient with dx of aphakia V 379.31
orV743.45. Replacement covered when
medically necessary (rx changes or worn out
items, lost, stolen or irreparably damaged items
– Proof of loss or damages required. New order
required
BILLING DMEPOS
• Most claims will need two CMS forms
• Patient preference items on separate CMS
forms except frame and progressive lenses
BILLING DMEPOS
• Modifiers
– KX must be used on medically necessary
options and have supporting documentation on
file
– Only used for V2750, V2744, V2745, V2780,
V2784
– If coverage criteria not met, the GA or GZ
modifier must be used
BILLING DMEPOS
• Modifiers
– GA Must be used if a properly executed ABN
has been signed
– GZ Must be used if a valid ABN not obtained
(will be a provider write off)
– EY No physician order on file for this item.
(Only forV2750,V2744,V2745,V2780,V2784)
– EY and GA modifiers go together
BILLING DMEPOS
• Modifiers
– RT and LT modifiers must be used with all lens
V codes except frames and low vision aids
– When lenses are provided bilaterally and the
same code is used for both lenses, bill both
codes on same line with RT LT modifier and 2
units of service
BILLING DMEPOS
• Documentation – Verbal order
– Supplier may dispense refractive lenses on a
verbal order followed by a written order.
Verbal order must include the following
elements
•
•
•
•
Description of items
Name of beneficiary
Name of Physician
Date of order
BILLING DMEPOS
• Documentation – Written order
– Must contain following elements
• Beneficiary’s name
• Detailed description of items
• All options or additional features
• Signature of prescribing physician
• Date the order is signed
BILLING DMEPOS
• Documentation – Proof of delivery
– Required to verify the patient actually received
the lenses
– Must be available upon request and if not, an
overpayment letter is sent
– Must have patient name, detailed description of
item, patient signature,
– Suppliers, their employees or anyone having
financial interest cannot sign on behalf of
beneficiary
BILLING DMEPOS
• Documentation – Misc.
– Signed authorization to bill Medicare and
assign benefits to provider from patient
– CMS Medicare DMEPOS supplier standard
form given to patient and noted in chart
– Possible ABN form
BILLING DMEPOS
• Common claim errors for refractive lenses
– Item 17b – NPI missing or inaccurate. Must be
listed in PECOS
– Item 21 – Invalid diagnosis code
– Item 24a – Inaccurate date of service – date of
service is the date beneficiary receives the item,
not the date the item was ordered
– Item 24b – Non covered place of service. POS
should never be 11 for DMEPOS items. POS
should indicate where the beneficiary will use
the item. (Generally POS 12-home)
GLAUCOMA CODES
(BORDERLINE CODES)
• 365.00, (EXISTING) - (Pre-Glaucoma, unspecified)
• 365.01, (revised def.) – Open angle with borderline
findings, low risk
• 365.02, (revised def.) – Anatomical narrow angle,
primary angle closure suspect)
• 365.03, (existing) – Steroid responders
• 365.04, (existing) – Ocular hpertension
• 365.05, (new) – Open angle, with borderline findings,
high risk
• 365.06, (new) – Primary angle closure without
glaucoma damage
NEW GLAUCOMA
STAGE CODES ADDED
(TO BE USED WITH EXISTING GLAUCOMA CODES)
(365.10-.15) (365.20-.24) (365.31-.32) (365 .51 .52 .59) 365.60-.65)
•
•
•
•
•
365.70 – GLAUCOMA STATE UNSPECIFIED
365.71 – MILD STAGE GLAUCOMA
365.72 – MODERATE STAGE GLAUCOMA
365.73 – SEVERE STAGE GLAUCOMA
365.74 – INDETERMINATE STAGE
GLAUCOMA
DEFINITION OF GLAUCOMA STAGES
• MILD: Optic nerve changes consistent with glaucoma
but NO visual field abnormalities on any visual field test
OR abnormalities present only on Visual Field tests
• MODERATE:
Optic nerve changes consistent with
glaucoma AND glaucomatous visual field abnormalities in
one hemifield and not within 5 degrees of fixation.
• SEVERE:
Optic nerve changes consistent with
glaucoma AND glaucomatous visual field abnormalities in
both hemi-fields and/or loss within 5 degrees of fixation in
at least one hemi-field
Glaucoma Code Notes
• Code stage codes 365.71-74 immediately after
primary diagnostic code.
• Must correlate with patient’s worse eye
• Stage codes for mild, moderate, and severe will
be most common used.
• Unspecified and indeterminate terms often result
in denial or request for additional documentation
Electronic Health Records
(EHR)
• http://www.cms.gov/EHRIncentivePrograms/
January 2012: Final updates in
Medicare, ICD-9 & CPT codes
archived webinar
http://www.aoa.org/x18392.xml#med-records-coding
ICD-10
• Originally October
st
1 ,
2013
• Postponed to a later date that is
currently unkown
COMPLYING WITH MEDICARE
SIGNATURE REQUIREMENTS
• In order for a signature to be valid, the
following criteria must be met:
– Services provided or ordered must be
authenticated by the ordering practitioner
– Signatures are handwritten or electronic
(stamped signatures are not acceptable)
– Signatures must be legible
COMPLYING WITH MEDICARE
SIGNATURE REQUIREMENTS
• You may not add late signatures to medical records. If the
practitioner’s signature is missing from the medical record,
you may submit an attestation statement from the author.
• If you are audited and accused of a non-legible signature,
you may submit a signature log attestation statement to
support the identify of the illegible signature.
• What is a signature log
– A typed listing of the provider(s) identifying their name
with a corresponding handwritten signature
– You may create a signature log at any time
– You may attest that a signature is yours by preparing a
statement signed by the author that the signature is, in
fact his.
COMPLYING WITH MEDICARE
SIGNATURE REQUIREMENTS
–
Signatures must contain enough information to
determine the date on which the service was performed/
ordered. If the entry immediately above or below the entry
is dated, medical review may reasonably assume the date of
the entry in question.
–
–
–
Guidelines for electronic signatures are;
Software products must include protections against
modifications
The individual whose name is on the electronic
signature bears the responsibility for the authenticity
of the signature
Part B and DME providers must use a qualified
electronic prescribing system
UPDATE OF CURRENT TRENDS IN
WA LABOR AND INDUSTRIES
• New Provider List:
Am I going to be included?
Do I have to re-apply?
How do I re-apply?
http://www.lni.wa.gov/ClaimsIns/Providers/Bec
oming/Network/Default.asp
AN OVERVIEW OF DSHS BILLING AND
CODING INFORMATION
• Provider Publications Home Page:
http://hrsa.dshs.wa.gov/download/Index.htm
• ProviderOne Billing and Resource Guide:
http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_a
nd_ Resource_Guide.html
• Vision Hardware for Clients 20 Years of Age and
Younger Billing Instructions:
http://hrsa.dshs.wa.gov/download/Billing_Instructions_
Webpages/Vision_Care.html
• Physician Related Services/Healthcare
Professional Services Medicaid Provider Guide:
http://hrsa.dshs.wa.gov/download/Billing_Instructions_
Webpages/Physician-Related_Services.html
(the Vision Care Services portion is located in Section B)
THE MECICARE LEARNING
NETWORK (MLN)
“Everything you want to know about
Medicare for the OD”
• http://www.cms.gov/MLNProducts/65_ophthalm
ology.asp#TopOfPage
–
–
–
–
–
–
–
–
Physician fee schedule lookup;
Physician fee schedule overview
Glaucoma screening
Age-related Macular Degeneration
NCCI Edits (How to use)
IOL technology
MLN ordering page
MLN Articles
HOW TO?????????
• How to Search the Medicare Physicians Fee Schedule
booklet provides education on how to use the Medicare
Physician Fee Schedule (MPFS), search for payment,
pricing, (RVUs), and payment policies.
http://www.cms.gov/MLNProducts/downloads/How_to_M
PFS_Booklet_ICN901344.pdf
• How to Use the Medicare Coverage Database and How
to use the National Correct Coding Initiative (NCCI)
Tools.
https://www.cms.gov/MLNProducts/downloads/Medicar
eCvrgeDatabase_ICN901346.pdf
• Other Products From the Medicare Learning
Network®.
http://www.cms.gov/MLNProducts/
WHAT EVERY OFFICE SHOULD
HAVE FOR EFFICIENT BILLING
CODES FOR OPTOMETRY 2012 Order through AOA
communications department. www.aoa.org or
http://asoa.codingtoday.com/
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ACCESS TO AOA CODING TODAY ON THE AOA
WEBSITE AT:WWW.AOA.ORG/CODING.
ACCESS TO THE UPDATED OPW
INSURANCE LIAISON WEB PAGE AT
WWW.EYES.ORG
WHAT EVERY OFFICE SHOULD
HAVE FOR EFFICIENT BILLING
 COMPUTERIZED FEE CALCULATION
SOFTWARE TO ESTABLISH YOUR FEES &
EXACT INSURANCE REIMBURSEMENTS.
QUESTIONS ?