Vision Services
HP Provider Relations
October 2011
Agenda
– Objectives
– Billing Procedures
– Enhanced Code Auditing
– Clear Claim Connection
– Lenses
– Frames
– Benefit Limit Verification
– Prior Authorization
– HIPAA 5010
– Common Denials
– Find Help
– Q&A
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Vision Services
October 2011
Objectives
– To provide a comprehensive overview of
Indiana Health Coverage Programs
(IHCP) policy regarding vision services
– To explain billing and coverage
guidelines for vision services
– To inform providers when it is
appropriate to bill members for
noncovered vision services
– To review the most common denial
codes for vision claims
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Vision Services
October 2011
Reference Material
– Ophthalmological services are outlined in the IHCP Provider Manual,
Chapter 8 Section 4
– 405 IAC 5-23 (Indiana Administrative Code)
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Vision Services
October 2011
Understand
Billing Procedures
Provider Code Sets
– The IHCP established provider code sets for Opticians,
specialty 190, and Optometrists specialty 180
– Enrolling in the 190 specialty does not necessarily cover
services in the 180 specialty, and enrolling in the 180 specialty
does not necessarily cover services in the 190 specialty
– Providers must ensure that they are enrolled as the correct
provider type and specialty and bill the appropriate code set
– Type and specialty can be verified using the Provider Profile
menu option on Web interChange
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Viewing Provider Code Sets
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Vision Services
October 2011
Coverage and Billing Procedures
– The IHCP provides reimbursement
for ophthalmology services, subject
to the following restrictions:
• One routine vision care examination and
refraction for members 20 years old and
younger, per rolling 12-month period
• One routine vision care examination and
refraction for members 21 years old and
older, per rolling 24-month period
• Routine vision examinations may be
performed more often than the 12- and 24month periods described above if they are
billed with a medical diagnosis
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Vision Services
October 2011
Routine Examinations
– The eye examination includes the following services, and
providers should not bill them separately:
15
•
Biocular measurement
•
External eye examination
•
Gross visual field testing including color vision, depth perception, or stereopsis
•
Routine ophthalmoscopy
•
Tononmetry
•
Visual acuity determination
Vision Services
October 2011
Routine Examinations – Common Codes
The routine examination limitations will apply and will hit these error codes,
when the following procedure codes and diagnosis codes are billed together:
– Error code 6610 – Routine vision exam limited to one per 12 months, age
1-18
– Error code 6611 – Routine vision exam limited to one per 24 months, over
age 18
Procedure codes
Diagnosis codes
(not an all-inclusive list)
• V41, V410, V411
• 92002, 92004, 92012,
92014
• V72, V720, V80, V801, V802
• 99201-99215
• V367X
• 99241-99245
• 99251-99255
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
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Vision Services
October 2011
Routine Vision vs. Medical Examinations
– The diagnosis code related to the
specific procedure code should
reflect the conditions treated only on
that date of service
– Example: A patient is seen for eye
pain (379.91), but has a history of
hypermetropia/far sightedness
(367.0)
– If hypermetropia is not evaluated or
treated during the current visit, use
only diagnosis code 379.91
– If diagnosis code 367.0 is included
on the claim, the claim will be
considered a routine exam subject
to the limitations
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Vision Services
October 2011
Routine Vision vs. Medical Examinations
– When a patient is seen for both a
medical and routine vision service
on the same date, the primary
reason for the encounter should be
used to determine whether the
service falls under the routine or
medical benefit
– If the primary reason for the visit
was eye pain, but a routine vision
exam and refraction were
performed:
• The exam should be coded with the eye
pain (medical) diagnosis, and the refraction
should be coded with the routine diagnosis
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Vision Services
October 2011
Coverage and Billing Procedures
– Providers must use the appropriate Current Procedural
Terminology (CPT®) or Healthcare Common Procedure Coding
System (HCPCS) codes when submitting claims for vision
services
– Optometrists and opticians are subject to vision service code
sets, which are available at
provider.indianamedicaid.com/general-provider-services/billingand-remittance/code-sets.aspx
– Many vision procedure codes are on the Medicare bypass table
• Claims for "dually eligibles" do not have to be billed to Medicare first
• Exams/services (92002, 92004, 92012, 92014, 92015, 92065, 92315, 92316)
• Frames (V2020, V2025); lenses (V2100-V2615)
– All claims must reflect a date of service, which is the date the
specific services were actually supplied, dispensed, or rendered
to the patient
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Vision Services
October 2011
Vision Services and Package B
– Generally, a routine eye exam and refraction would not be
related to the pregnancy, a complication thereof, or a
condition that if left untreated would lead to a higher level of
care
– However, if the member’s primary medical provider (PMP)
has specifically referred the member for evaluation of a
condition that may affect the pregnancy, the service would be
covered under Package B
• Examples:
 Diabetes with retinopathy
 Severe eye infection
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Vision Services
October 2011
Learn
Enhanced Code Auditing
Enhanced Code Auditing
Why is the IHCP implementing the enhanced code auditing?
– The Indiana Health Coverage
Programs (IHCP) is implementing
enhanced code auditing into the
claims processing to support the
Office of Medicaid Policy and
Planning’s (OMPP’s) effort to promote
and enforce correct coding efforts for
more appropriate and accurate
program reimbursement
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Vision Services
October 2011
Enhanced Code Auditing
What supporting information is used for the new code auditing rules?
– Code auditing rules that have
been implemented represent
correct coding methodologies and
other coding methods based upon
general guidance from the Centers
for Medicare & Medicaid Services
(CMS), the American Medical
Association (AMA), specialty
society guidance, industry
standard coding, and prevailing
clinical practice
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Vision Services
October 2011
Enhanced Code Auditing
Multiple component billing
What is it?
– Identifies claims containing two or more procedure codes used to
report individual components of a service when a single, more
comprehensive procedure code exists that more accurately represents
the service performed
•
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Individual unbundled procedures will be denied
Vision Services
October 2011
Enhanced Code Auditing
Multiple component billing – Laboratory BT201102
– Effective for claims received on or after April 1, 2011
– Identifies when individual components of a bundled service are billed
separately rather than using the comprehensive CPT code
– Unbundled code line items will be denied:
• Edit
4186
Service denied. This is a component of a more comprehensive service. This service
is reimbursed under a distinct comprehensive code
Healthcare services should be reported with the procedure code that
most comprehensively describes the services performed
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Vision Services
October 2011
Enhanced Code Auditing
Multiple component billing – Example of lab panel rebundling
Line
Date of
Number Service
To Date of Procedure Description
Service
Code
Billed
Component
Amount Rebundling EOB
01
4/1/2011
4/1/2011
82040
Albumin; serum, plasma
or whole blood
$100
Detail is denied with
EOB 4186
02
4/1/2011
4/1/2011
82247
Bilirubin; total
$100
03
4/1/2011
4/1/2011
82248
Bilirubin; total direct
$100
04
4/1/2011
4/1/2011
84075
Phosphatase, alkaline
$100
05
4/1/2011
4/1/2011
84155
Protein, total, except by
refractometry; serum,
plasma or whole blood
$100
Detail is denied
EOB 4186
Detail is denied
EOB 4186
Detail is denied
EOB 4186
Detail is denied
EOB 4186
06
4/1/2011
4/1/2011
84450
Transferase; aspartate
amino (AST) (SGOT)
$100
Detail is denied with
EOB 4186
07
4/1/2011
4/1/2011
84460
Transferase; alanine
amino (ALT) (SGPT)
$100
Detail is denied with
EOB 4186
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Vision Services
October 2011
with
with
with
with
Enhanced Code Auditing
Changes to code auditing methodologies – BT201135
Effective for date of service
(DOS) on or after July 15, 2011,
the IHCP began applying code
auditing of the following:
– CMS-1500 claims that are
billed with multiple units of the
same laboratory code on the
same date of service
Edit 4189 - Multiple units of the
same laboratory service are not
payable for the same date of
service, same member, and same
or different provider without
medical necessity
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Vision Services
October 2011
Enhanced Code Auditing
Changes to code auditing methodologies – BT201135
– CPT add-on codes reported without reporting a corresponding primary
procedure/service
•
Edit 4190 – Add-on codes are performed in addition to the primary service or
procedure and must never be reported as a stand-alone code
– Reporting multiple units of a primary service when add-on codes
should be used
•
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Edit 4191 – A primary service or procedure code is limited to one unit per date of
service
Vision Services
October 2011
Enhanced Code Auditing
Changes to code auditing methodologies – BT201135
Effective for DOS on or after August 1,
2011, the system began applying code
auditing of the following:
– Non-anesthesia services submitted by
an anesthesia provider specialty where
the service billed is not normally
performed by an anesthesia provider
specialty
•
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Edit 4192 – Non-anesthesia services are not
reimbursable for the anesthesiology provider
specialty billed
Vision Services
October 2011
Enhanced Code Auditing
Changes to code auditing methodologies – BT201135
– Non-anesthesia services submitted by an anesthesia provider
specialty where there is a more appropriate anesthesia code that
should be used for billing
•
Edit 4193 – Non-anesthesia services are not reimbursable for the anesthesiology
provider specialty billed.
•
Claim lines containing non-anesthesia services submitted by an anesthesiology
provider specialty will be denied. Providers may resubmit the denied details with the
anesthesia code(s) as appropriate.
– These anesthesia-related code auditing rules apply only to providers
enrolled with the anesthesia specialty
•
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Multiple specialty providers will not be subjected to this type of code auditing
Vision Services
October 2011
Enhanced Code Auditing
Changes to code auditing methodologies – BT201135
Effective for dates of service on or after August 31, 2011, the
following code audits were implemented:
– Evaluation and management (E/M) codes billed on the same
date of services as a procedure with a global period
• Edit 4194 – Identifies procedure codes billed by the same provider on the same
date of service as a code with a global period
– E/M codes billed within the pre-operative period
• Edit 4196 – Identifies procedure codes billed by the same provider within a
procedure's preoperative period
Note - E/M services performed in a postoperative period that
are unrelated to a surgical procedure should only be reported
using the proper modifier
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Vision Services
October 2011
Enhanced Code Auditing
Billing reminders – Use of modifiers
– Modifiers may be appended to Healthcare Common Procedure
Coding System (HCPCS)/Current Procedural Terminology (CPT)
codes only when clinical circumstances justify them
– A modifier should not be appended to an HCPCS/CPT code solely
to bypass Component Rebundling auditing
•
The use of modifiers affects the accuracy of claims billing and reimbursement, and
Component Rebundling auditing
– Same procedures, performed during the same session
• Roll all the units to a single line, unless otherwise specified in medical policy
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Vision Services
October 2011
Announce
Clear Claim Connection
Clear Claim Connection
– Clear Claim Connection is a Web-based solution that enables HP and
the Office of Policy and Planning (OMPP) to share the National
Correct Coding Initiative (NCCI) claim auditing rules with providers
– The tool is for providers to perform claim analysis prior to submitting
the claim for processing
– Providers will have access to Clear Claim Connection through a link
within the Claim Submission menu option on Web interChange
• Web
interChange users must have access to Claim Submission to
use Clear Claim Connection
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Vision Services
October 2011
Clear Claim Connection
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Vision Services
October 2011
Clear Claim Connection
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Vision Services
October 2011
Clear Claim Connection
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Vision Services
October 2011
Clear Claim Connection – Overview
– Select the Clear Claim Connection link under the Code Auditing
menu
– Choose appropriate NPI if it is not currently populated
– Click the Continue button and click Agree on the Terms and
Agreement page to access the Clear Claim Connection
– Enter claim detail information to determine how the claim will process
according to the auditing rules set up in ClaimsXten McKesson
– Click Review Claim Audit Results to view the results
– Click New Claim to input information for another claim
– Click Current Claim to change the information on the current scenario
and continue with claim analysis
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Vision Services
October 2011
Define
Lenses
Lenses
– The IHCP only reimburses for tints
1 and 2
• V2745 U1 – Tint, plastic, rose 1 or 2, per
lens
• V2745 U2 - Tint, glass, rose 1 or 2, per
lens
– The IHCP covers safety lenses only
for corneal lacerations and other
severe intractable ocular or ocular
adnexal disease
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Vision Services
October 2011
Lenses – Noncovered
– The IHCP does not cover the following:
• V2702 – Deluxe lens feature
• V2744 – Tint, photochromic
• V2750 – Antireflective coating
• V2760 – Scratch resistant coating
• V2781 – Progressive lenses
• V2782 – Lens, index 1.54-1.65 plastic, or 1.60 to 1.79 glass
• V2783 – Lens, index >= 1.66 plastic, or >= 1.80 glass
• V2786 – Specialty multi-focal lens
– If a member chooses to upgrade to one of these codes
• Provider bills the IHCP for the basic lens code
• Provider may bill the member for the upgrade portion as long as
noncoverage is explained and a waiver is signed
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Vision Services
October 2011
Lenses
– Polycarbonate lenses
• Are covered only for medically necessary conditions that require additional
ocular protection
• Examples of medical necessity
Member has carcinoma in one eye, and the healthy eye requires corrective
lens
Member has eye surgery and still requires corrective lens
• Patient charts must support medical necessity
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Vision Services
October 2011
Lenses
– Contact lenses
• Are covered when medically necessary
• Examples of medical necessity
Severe facial deformity
Severe allergies to all frame materials
• Providers can bill the following codes, in addition to general ophthalmology
services
92310 through 92313 for prescription of optical and physical characteristics
of and fitting of contact lens
92314 through 92317 for prescription of optical and physical characteristics
of contact lens, with medical supervision
92325 for modification of contact lens, with medical supervision of
adaptation
92326 for replacement of contact lens
• Patient charts must support medical necessity
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Vision Services
October 2011
Describe
Frames
Frames
– The IHCP reimburses for frames including, but not limited to,
plastic or metal
• Procedure code V2020
– Deluxe or fancy frames are covered only when medically
necessary
• Procedure code V2025
 Examples
• Facial deformity
• Allergic reaction to standard frame material
• Provision of special sized frames for an infant
• Submit an invoice with the claim; reimbursement is 90% of retail price
– If the member chooses to upgrade to a deluxe frame, the entire
frame is noncovered, and the member can be billed
• Member must sign a waiver prior to service being rendered
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Vision Services
October 2011
Replacement Eyeglasses
– Members who have met medical necessity guidelines for replacement
eyeglasses are eligible for a new pair of eyeglasses
• Younger than 21 years of age: eligible one year from date IHCP provided their original
or replacement eyeglasses
• 21 years of age and older: eligible five years from date IHCP provided their original or
replacement eyeglasses
– The member must meet the following medical necessity guidelines in
at least one eye for the provision of eyeglasses, including
replacements
• A change of 0.75 diopters for patients 6 to 42 years old
• A change of 0.50 diopters for patients more than 42 years old
• An axis change of at least 15 degrees
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Vision Services
October 2011
Modifiers for Replacement Eyeglasses
– Replacement eyeglasses due to loss,
theft, or damage beyond repair, prior to
the frequency guidelines, should be
billed with modifier U8
– Replacement eyeglasses due to
change in prescription, prior to the
frequency guidelines, should be billed
with modifier SC
– Use of either modifier indicates
appropriate documentation is on file in
the patient’s record to substantiate the
need
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Vision Services
October 2011
Learn
Benefit Limitation Verification
Billing Members
Providers may bill IHCP members for services exceeding the
benefit limitations under the following circumstances:
– If the Eligibility Verification System (EVS) shows that a limitation
has been met:
• Inform the member the service will be noncovered and they will be billed
• Have the member sign a waiver
– If EVS does not show that benefits have been exhausted:
• Provider may ask the member or guardian to attest in writing that they have not
received the service within the past one or five years (depending on age)
• Inform the member if they are misrepresenting, and the claim is denied, the
member will be responsible for the charges
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Vision Services
October 2011
Written Correspondence
– Providers may send an inquiry to the
HP Written Correspondence Unit to
determine whether a member has
exceeded service limitations
HP Provider Written Correspondence
P.O. Box 7263
Indianapolis, IN 46207-7263
– Allow 10 business days for a
response
• Responses are mailed to the “Pay To"
address
– Use IHCP Inquiry Form
• Available at indianamedicaid.com
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Vision Services
October 2011
EVS – Benefit Limits Reached
– The Benefit Limits Reached
information on vision services
contained in the Eligibility
Verification System may not
always be up to date on members
covered by the Hoosier
Healthwise, risk-based managed
care program
– Providers should contact the
managed care entity (MCE) vision
plan to inquire about vision
services benefit limits
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Vision Services
October 2011
Business Practice to Restrict Services
– Providers may establish a business practice to refuse or restrict
certain services that are provided to the general public
– The provider must establish a written policy to do so
– If a provider intends to provide exams, diagnostic services,
surgical services, but will not provide eyewear, the member
must be advised at the time the appointment is made that the
provider does not provide “IHCP approved glasses"
– A prescription may be provided for the member to have filled at
a participating eyewear provider, or the member may choose to
find another provider that will furnish both services
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Vision Services
October 2011
Explain
Prior Authorization
Prior Authorization
– For Traditional Medicaid, prior
authorization is not required for vision care
services except for the following
provisions:
• Blepharoplasty for a significant obstructive
vision problem
• Prosthetic device, except eyeglasses
• Reconstruction or plastic surgery
– Contact ADVANTAGE Health Solutions for
PA for traditional and Care Select members
P.O. Box 40789 Indianapolis, IN 46240
1-800-269-5720 Fax: 1-800-689-2759
– Risk-based managed care MCEs may have
additional prior authorization requirements
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Vision Services
October 2011
Understand
HIPAA 5010
HIPAA 5010
– The mandatory compliance date for
ANSI version 5010 and the National
Council for Prescription Drug
Programs (NCPDP) version D.0 for all
covered entities is January 1, 2012
– If submitting claims to the IHCP, you
need to prepare for these upgrades to
prevent delay in payment
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Vision Services
October 2011
HIPAA 5010
– Transactions affected by this upgrade:
• Institutional claims (837I)
• Dental claims (837D)
• Medical claims (837P)
• Pharmacy claims (NCPDP)
• Eligibility verifications (270/271)
• Claim status inquiry (276/277)
• Electronic remittance advices (835)
• Prior authorizations (278)
• Managed Care enrollment (834)
• Capitation payments (820)
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Vision Services
October 2011
Testing Information
– All trading partners currently approved to submit 4010A1 and
NCPDP 5.1 versions will be required to be approved for 5010
and D.0 transaction compliance
• All software products used to submit 4010 and NCPDP 5.1 versions must be
tested and approved for 5010 and D.0
– Providers that exchange data with the IHCP using an IHCPapproved software vendor will not need to test
– Each trading partner will be required to submit a new
Trading Partner Agreement
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Vision Services
October 2011
What You Need To Do
– If you bill IHCP directly
• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
– If you are using a billing service or clearinghouse
• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and
NCPDP vD.0
• IHCP Companion Guides are available at indianamedicaid.com
– Questions should be directed to INXIXTradingPartner@hp.com
OR
– Call the EDI Solutions Service Desk
• 1-877-877-5182 or (317) 488-5160
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Vision Services
October 2011
Deny
Most Common Denials
Edit 0593 – Medicare Denied Detail
– Cause
• Medicare has denied at least one detail line on the claim
– Resolution
• Denied detail lines must be rebilled on a separate claim form
• Do not submit claim as a crossover
• Include the Medicare Remittance Notice (MRN) with the claim with the reason
for the denial
Remember: Many vision codes are on the Medicare bypass table and do not
need to be billed to Medicare
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Vision Services
October 2011
Edit 4021 – Procedure Code vs. Program
Indicator
– Cause
• Procedure code billed is restricted to a specific program
− Package B, C, E
− 590 Program
– Resolution
• Verify eligibility prior to rendering service
• Submit claim with appropriate procedure code
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Vision Services
October 2011
Edit 268 – Billed Amount Missing
– Cause
• The billed amount is missing from one of the detail lines
• The billed amount is missing from field 28 of CMS-1500 claim form
– Resolution
• Verify each detail line has a billed amount
• Enter the total billed amount in field 28
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Vision Services
October 2011
Edit 5001 – Exact Duplicate
– Cause
• Claim is an exact duplicate of a claim in the history file or another claim being
processed in the same cycle
– Resolution
• Research prior claims for a paid status
 Web interChange
 HP Customer Service Center
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Vision Services
October 2011
Edit 2017 – Recipient Ineligible on DOS Due
to Enrollment in Managed Care Entity
– Cause
• The member was not eligible for Traditional Medicaid on the date of service
because they were enrolled in the risk-based managed care (RBMC) program
– Resolution
• Verify eligibility prior to rendering service to see if the member is in RBMC
• Bill the appropriate managed care entity (MCE)
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Vision Services
October 2011
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– IHCP Web site at indianamedicaid.com
– IHCP Provider Manual (Web, CD, or paper)
– EVS Technical Support
•
HP Electronic Solutions Help Desk at 1-877-877-5182
– Customer Assistance
• Local
• All
(317) 655-3240
others 1-800-577-1278
– Written Correspondence
• HP
Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
– Provider field consultant
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Vision Services
October 2011
Q&A