Understanding Medicare
Guidelines - 2009
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
 314.569.1596 FAX
 jamod1@aol.com

JAM
2009 Medicare E/M Guidelines

Compliance
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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
2006 New HCPCS Codes

V2788 Presbyopia-correction function of an
intraocular lens
–
–
–
For reporting additional, non-covered charges associated
with the insertion of the presbyopia correcting IOLs
Effective Jan. 1, 2006
Recommend ABN
JAM
Multifocal IOLs

“Presbyopia-correcting IOLs allowed by CMS on May
3, 2005
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ReSTOR
ReZoom
CrystaLens
2006 New CPT Codes

Pegaptanib for AMD
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
Verteporfrin for AMD
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
67028 Intravitreal injection - $196.58
J2503 Macugen - $1054.70
67221 infusion of photodynamic agent - $301.46
J3396 Visudyn - $1400
Bevacizumab for AMD
–
–
67028 Intravitreal injection - $196.58
J9035 Avastin
JAM
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
2007 New CPT Codes

92025 Computerized Corneal Topography,
Unilateral or Bilateral, with Interpretation & Report
–

Fee $28.39
67346 Biopsy of Extraocular Muscle
JAM
2007 New ICD-9 Codes
377.43 Optic Nerve Hypoplasia
 379.60 Inflammation (infection) of post procedural
bleb; unspecified
 379.61 Inflammation (infection) of post procedural
bleb; stage 1
 379.62 Inflammation (infection) of post procedural
bleb; stage 2
 379.63 Inflammation (infection) of post procedural
bleb; stage 3

JAM
2008 New CPT Codes

68816 Probing of nasolacrimal duct w or w/o irrigation,
with transluminal balloon catheter dilation
–


Fee $551.79
67041
67042

67043
67113

67229

Vitrectomy w removal of ERM
Vitrectomy w removal of ILM for repair of
DME, or macular hole
Vitrectomy w removal of CNV
Repair of complex RD (PVR, diabetic
traction RD, ROP, tear >90 degrees) w
vitrectomy and membrane peeking, includes
everything
Preterm infant (<37wks gestation, birth to one yr),
photocoagulation or cryopexy (ex ROP)
JAM
2008 New ICD-9 Codes

364.89 Other disorders of the iris and ciliary body
(prolapse, NOS)
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
V49.85 Dual sensory impairment
–

Blindness with deafness
V68.01 Disability examination
–

Excludes prolapse of iris in recent wound
Use additional code to identify specific examination,
screening, and testing performed (V72.0-V82.9)
364.81 Floppy iris syndrome*
–
Can’t use for 66982
JAM
2009 New CPT Codes

0198T
65756
 65757

Measurement of ocular blood flow by
repetitive IOP samples, with interpretation
& report
Keratoplasty, endothelial
Backbench preparation of corneal
endothelial allograft prior to transplantation
JAM
2009 New ICD-9 Codes
362.2
 362.22
 362.23
 363.24
 362.25
 362.26
 362.27
 364.82
 372.34

Retinopathy of prematurity, unspecified
ROP stage 0
ROP stage 1
ROP stage 2
ROP stage 3
ROP stage 4
ROP stage 5
Plateau iris syndrome
Pingueculitis
JAM
Job Growth and Tax Relief Reconciliation
Act of 2003
Bush signed May 28, 2003
 3rd largest tax cut in history
 Encourages businesses to increase capital spending

–
Section 179 expense limit increased to $250,000.00 for
equipment put in service by 12.31.08
 Purchased
can be financed and interest expense is also deductible
 Applies to leased or pre-owned equipment
JAM
Tax Relief and Health Care Act of 2006

Set conversion factor for physician payment at same
level as in 2006
–
–
Reverses statutory mandated 10.6% negative update for 6
months
“Deal” provides for
 0.5%
fee increase
 Extends expiring incentive payments for rural physicians
 Extends bonus payments for quality reporting
JAM
Health Insurance Portability and
Accountability Act of 1996

President Clinton & USAG J. Reno
–
–
–
–
–
–
–
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#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
Dead Doctors Billing Scams 2000-2007
478,500 false claims
 16,500 dead physicians
 $92.8 million in payments just by Medicare
 16% made by doctors dead for more than 10 years

JAM
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
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
Top 5 Errors by Profession - 2006
OB/GYN
 Neurology
 Chiropractic

Optometry

– 11.6%
Nephrology
JAM
Medicare Review Strategies - 2009
E/M established codes
 Laboratory
 Hospital E/M, subsequent
 Consultation codes
 E/M new codes
 Electrocardiograms
 Chiropractic
 Rituximab
 Hospital E/M, initial

JAM
Top 10 Procedure Codes – Optometry
Missouri / Jan-June 2007 / 495 Providers
92014
 99214
 92004
 92012
 99213
 66984
 92250
 92083
 99203
 92135

$1,369,645
$ 634,210
$ 562,906
$ 551,297
$ 541,616
$ 395,125
$ 339,862
$ 277,708
$ 199,510
$ 195,427
JAM
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
AOA Optometric Practice Profiles 2005
VSP – 21%
 Other vision plans – 8%
 Medicare – 19.1% (fastest growing share of revenues)
 Medicare HMOs – 3%
 Medicaid – 7%
 HMOs (private sector) – 8%
 Out of pocket – 35%
 Respondents - 90% self-employed, 47% solo, 24%
group, 86% male, mean years in practice 24.2 years

JAM
INTRODUCTION

CMS = Center for Medicare & Medicaid Services
(formerly HCFA) - announced June 14, 2001
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–
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Center for Medicare Management - traditional fee-forservice 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
INTRODUCTION
CMS
 CPT
 ICD

–
www.icd9coding1.com/flashcode/userRegister.do
Medicare
 Major Medical
 E/M Coding (99XXX)
 Eye Coding (92XXX)
 Special Ophthalmic Codes

JAM
E/M GUIDELINES
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New/Established Patient
Chief Complaint
History of Present Illness
Family History
Past History
Social History
–


New additions level of education, sexual history, marital status/living
arrangements
Review of Systems
Time
JAM
E/M DESCRIPTORS
History *
 Examination*
 Medical Decision Making*
 Counseling
 Coordination of Care
 Nature of the Presenting Problem
 Time

JAM
CATEGORIES OF SERVICE

Office Visits (E/M Codes)
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–

99201-99205
99211-99215
Office Visits (Eye Codes)
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–

New
Estab
New
Estab
92002-92004
92012-92014
Consultations (E/M Codes)
–
Office
99241-99245
JAM
E/M Coding - Consultation

Office Consultations
–
–
Opinion / Advice
Not Referral
Duration - short
 Continuity - expect patient back
 Documentation - required

JAM
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
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
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
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
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
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
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
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
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

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
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
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
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.

specifically describe “routine
exams” including refractions and permit a
 They
different charge
JAM
HCPCS “S” Codes
S0592
 S0620
Complicated contact lens evaluation
Routine ophthalmologic exam including
refraction; new patient
S0621
Routine ophthalmologic exam including
refraction; established patient


JAM
2006 Medicare Fee Schedule
Office Visits

99201
 99202
 99203
 99204
 99205
$34.23$60.83$90.58$128.26$163.20-
99211
99212
99213
99214
99215
$19.96$35.96$49.10$77.08$112.36-
92002
 92004
$66.03$120.51-
92012
92014
$60.50$89.53-

JAM
2006 Medicare Fee Schedule
Consultations
99241
 99242
 99243
 99244
 99245

$46.96$86.00$114.67$162.01$209.65-
JAM
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
Gonioscopy
92020
Bilateral
 Requires documentation

–
describe visible angle structures
No limitations to diagnostic groups in most states
 Fee
$25.47

JAM
Visual Field 9208x
Bilateral
 Requires Interpretation

–
–
separate report form
narrative in body of medical record, on date of service
Fee (-81) / $46.18
 Fee (-82) / $59.09
 Fee (-83) / $68.17

JAM
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 ($21.69) 92226 ($19.53)
JAM
Fundus Photography
92250




Bilateral
Not Bundled
Requires Interpretation
Fee $69.46
JAM
Fundus Retinal Photos ROI






Synemed (Canon 10+MP)
Cost $24,500.00
Lease $543.90
Breakeven 2 photos / wk
8-10 MP digital nonmydriatic
10 images / wk – lease =
$22,273.20 annual revenue
Fluorescein Angiography 92235
Indocyanine-Green 92240
Unilateral
 Not Bundled
 Requires Interpretation & Report
 Fee 92235 ($122.55)
92240 ($254.30)

JAM
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
$42.12

JAM
Special Anterior Segment Photography
92286

With specular endothelial microscopy and cell count
–
Ex: Konan specular microscope
Bilateral
 Not Bundled
 Requires Interpretation and report
 Fee
$101.04

JAM
Special Anterior Segment Photography
92286

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

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
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


364.00-364.04 iridocyclitits
364.10-364.11 chronic iridocyclitis
364.21 Fuch’s heterochromic iridocyclitis
364.22 glaucomatocyclitic crisis
364.23 lens induced iridocyclitis
364..24 VKH syndrome
364.51 essential iris atrophy
364.52 iridoschisis
364.53 pigmentary iris degeneration
364.54 pupillary margin degeneration
JAM
Special Anterior Segment Photography
92286
364.55 Miotic Cysts of pupil margin
 364.56-364.61 degenerative changes of anterior
structures
 366.21-23 Traumatic cataract
 366.32 cataract in inflammatory disorder
 366.33 cataract in ocular neovascularization
 371.20-24 corneal edemas
 371.32-33 folds or rupture in descemet’s membrane
 371.50, -.57,-.58, corneal dystrophy

JAM
Special Anterior Segment Photography
92286

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







371.82 corneal edema due to contact lens
379.31 aphakia
379.32 subluxation of lens
379.32 anterior displacement of lens
743.20-23 buphthalmos
906.5 late effect of burn of eye/face
940.2 alkaline burn of cornea/conj
940.3 acid burn of cornea/conj
940.4 other burn of cornea/conj
V42.5 cornea replaced by transplant
JAM
Special Anterior Segment Photography
92286







996.51 mechanical complication of prosthetic corneal graft
996.60 infection/inflammation due to unspecified implant and
graft
996.69 complication of other implant or graft
998.89 complication of other transplanted organ
998.59 other postoperative infection
998.82 cataract fragments in eye following cataract surg
V53.1 fitting & adjusting specs or CL after intraocular surgery
JAM
Computerized Corneal Topography
92025
Bilateral or unilateral
 Requires interpretation & report
 No limitations to diagnostic groups in most states
 Fee
$23.12- / $28.47

JAM
92025 Corneal Topography

ICD-9 Codes that Support Medical Necessity
–
–
–
–
–
–
–
–
367.22* Irregular astigmatism
371.00 Corneal Opacity Unspecified
371.23 Bullous Keratopathy
371.50 Hereditary Corneal Dystrophy Unspecified
371.52 Other Anterior Corneal Dystrophy
371.57 Endothelial Corneal Dystrophy
371.60 Keratoconus Unspecified
371.61 Keratoconus Stable Condition
JAM
92025 Corneal Topography

ICD-9 Codes that Support Medical Necessity
–
–
–
–
–
–
–
–
–
371.62 Keratoconus Acute Hydrops
372.40 Pterygium Unspecified
996.51 Mechanical Complication Prosthetic Corneal Graft
V42.5 Cornea Replaced by Transplant
V45.61* Cataract Extraction Status
V45.69* Other States Following Surgery of Eye /Adnexa
*367.22 must be accompanied by V45.61 or V45.69
*V45.61 must be accompanied by 367.22
*V45.69 must be accompanied by 367.22
JAM
Therapeutic Contact Lens
92070
Unilateral
 Bundled with 92xxx, includes supply of lens
 Recommendations

–
–
–
–
–

use disposable lenses
accept a less than optimum cosmetic fit
tolerate debris on and beneath lens
remove only once and do not replace
liberally hydrate prior to removal
Fee
$58.93-/62.97
JAM
RPS Adeno Detector™
Test Procedure
Collecting the Sample
4. Dab the sampling pad inside
the lower eyelid (palpebral
conjunctiva)
4 – 6 times.
Allow the sampling pad to rest
against the conjunctiva
(membrane on inside of the
eyelid) for an additional 3
seconds to ensure saturation of
the sampling pad with eye fluid.
RPS Adeno Detector™
Test Procedure
Assembling the Detector
1. Locate the Test Cassette
2. Assemble the detector by gently
placing the sampling pad of the
Sample Collector into the
sample transfer window of the
Test Cassette body.
3. Press firmly where indicated until
the detector is secure.
Transfer Window
Note: A double auditable click means the detector
is properly assembled, transferring the sample to the test strip.
RPS Adeno Detector™
Test Procedure
Running the Test
1. Open the buffer vial. Remove
the Protective Cap from the
Test Cassette. Do not allow
any portion of the detector
besides the absorbent tip to
touch the buffer vial.
2. Immerse the Assembled
Detector’s Absorbent Tip into
the buffer vial for 15 seconds.
RPS Adeno Detector™
Reading & Interpreting the Results
Positive Results:
The Results Line and Control Line are RED in the result window,
indicating that Adenovirus antigen is present.
Results Line
Control Line
Control Line
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
–
–

ICD-9 Negative test result
–
–

077.3 other adenoviral conjunctivitis; acute follicular conj
077.99 other diseases of conjunctiva due to viruses
372.02 Acute follicular conjunctivitis, excludes EKC, PCF
372.05 Acute atopic conjunctivitis
Fee $17.76
JAM
Serial Tonometry
92100
Bilateral
 Requires Interpretation & Report

–
–

Example: Angle closure glaucoma
multiple measurements over time
Fee
$85.60
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging
92135


Unilateral
Applies to glaucoma and retinal evaluations
–
–
–
–


Heidelberg / Heidelberg Retinal Topography (HRT3, Spectralis)
Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)
Optovue / (RTVue)
Marco / Retinal Thickness Analyzer (RTA)
Requires Interpretation & report
Fee $45.64
JAM
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
JAM
 377.9 unspecified disorder of optic nerve or pathways

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
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
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
$11.42

JAM
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
Correction Trichiasis
67820*
Epilation
 By forceps
 ICD-9

–
–

374.05 Trichiasis without entropion
374.01 Senile entropion
Fee
$54.29
JAM
Multiple Punctures of
Anterior Cornea
65600
Unilateral
 Stromal Tattoo
 25 gauge needle
 ICD-9

–

371.70 Unspecified Corneal Deformity
Fee
$301.86
JAM
Removal of Foreign Body
65205*

External Eye, Conjunctiva
–
–

ICD-9
–

superficial
scleral, non-perforating
930.18 FB in cul-de-sac
Fee
$48.82
JAM
Removal of Foreign Body
65210*

External Eye, Conjunctiva
–
–
–

ICD-9
–

embedded (includes concretions)
subconjunctival
scleral, non-perforating
930.18 FB in other sites or combined sites
Fee
$59.74
JAM
Removal of Foreign Body
65222*

External Eye, Corneal
–

ICD-9
–

with Slit Lamp
930.0 FB in cornea
Fee
$65.75
JAM
Sensorimotor Examination
92060

Quantitative measurement of ocular deviation
–
document all major fields of gaze
Bilateral
 Requires interpretation and report
 Fee
$48.93 92065 – Orthoptic and / or pleoptic training, with
continuing medical direction and evaluation
 Fee
$32.38

JAM
Dilation of Lacrimal Puncta
68801*
With or Without Irrigation
 ICD-9

–
–
–
–

375.22 Epiphora, insufficiency of drainage
375.42 Chronic Dacryocystitis
375.52 Stenosis, Lacrimal Punctum
375.56 Nasolacrimal Duct Obstruction
Fee $103.08
JAM
Prolonged Physician Service
99354/99355
Office or other outpatient setting
 Direct patient contact beyond the usual service
 List separately in addition to code for office or other
outpatient E/M service

–
–
–
–
<30min
30-74min
75-104min
105-134min
 99355
Not reported separately
99354 X 1 (Fee $84.88-/$93.36)
99354 X 1 and 99355 X 1
99354 X 1 and 99355 X 2
- each additional 30 minutes
(Fee $84.20/$92.33)
JAM
Punctal Occlusion By Plug
68761
Temporary (collagen) or Permanent (Silicone)
 Payment is per puncta (modifiers required)

–
–
E1=left upper
E2=left lower
E3=right upper
E4=right lower
Global period - 10 days
 Supply code-included in procedure code, not separately
billable
 Fee
$130.02

JAM
Punctal Occlusion By Plug
68761

ICD-9
–
–
–
–
–
–
–
–
–
370.21 Punctate Keratitis
370.23 Filamentary Keratitis
370.34 Exposure Keratitis
370.80 Other forms of Keratitis
370.90 Unspecified Keratitis
371.42 Recurrent Corneal Erosion
374.41 Eyelid Retraction
375.15 Unspecified Tear Film Insufficiency
710.20 Sicca Syndrome; use additional systemic manif.JAM
code
Modifiers
–
–
–
–
–
–
–
–
–
–
–
79 Inside post-operative global period
50 Bilateral Procedure
24 Unrelated Service / Same Doctor
79 Inside Global Period
25 Separate Service / Same Doctor / Same Day
52 Reduced Service / Informational / Not Reduced Fee
54 Surgical Care Only
55 Post-Op Care Only
51 Multiple Procedures
RT / LT Right / Left
E 1- E4 Identifies Puncta
JAM
Comanagement of Surgery
Procedures / 66984 / $639.69
 Global Periods - usually 90 days
 Value - up to 20%
 Modifiers (-54,-55)
 Range Dates
 Rules - Medicare Transfer Agreement in MD record
 Correspondence
 Legal/Political/Inter-professional Issues

JAM
Complicated Cataract Surgery
66982
New CPT code for 2001 / $850.80
 Extracapsular cataract extraction with insertion of
IOL, complex, requiring devices or techniques not
generally used in routine cataract surgery

–
2-3% of all cataract surgeries involve extraordinary work
 iris
expansion devices, suture support for IOL, posterior
capsulorrhexis, small pupil, subluxed lens, Pseudoexfoliation,
trauma, Marfan’s, glaucoma, uveitis
 pediatric population
 Advanced, white, hard cataract
JAM
CASE 1: Cataract

CPT / ICD
–
–
–
92015 / Myopia (367.1) = $20.00
99203 / Cataract (366.16) = $95.00
Total $115.00
Rx: Spectacles
 RTO: 1YR
 CPT / ICD

–
–
–
92015 / Myopia (367.1) = $20.00
99214 / Cataract (366.16) = $80.00
Total $100.00
JAM
CASE 2: Blepharoconjunctivitis

CPT / ICD
–
99213 or 92012 / Blepharitis (373.00) = $50.00 or $63.00
Rx: Bacitracin Oint hs / Tobradex qid / Lid Hygiene /
AFTs
 RTO: 1 WK
 CPT / ICD

–
–
99212 / Blepharitis (373.00) = $$45.00
Total $95.00 or $108.00
JAM
CASE 3: Allergic Conjunctivitis

CPT / ICD
–
–
99213 or 92012 / Conjunctivitis allergic (372.14)
$50.00 or $63.00
Rx: Pataday QD / Cold Packs / AFTs
 RTO: 1 WK
 CPT / ICD

–
–
99212 or 92012 / Conjunctivitis, allergic (372.14) = $$45.00
or $63.00
Total $95.00 or $126.00
JAM
CASE 4: Rosacea (Skin & Eye)

CPT / ICD
–
–
–
99213 or 92012 Meibomianitis (373.12) / Acne Rosacea
(695.30) = $50.00 or $63.00
92285 / (370.01) Marginal keratitis = $45.00
Total $ 95.00 or $108.00
Rx: Zylet QID / Lid Hygiene / Minocycline 50mg BID /
MetroCream 0.75% BID RTO: 2 D
 CPT / ICD

–
–
99212 or 99213 / Meimbomianitis (373.12) = $50.00 or$63.00
Total $145.00 or 171.00
JAM
CASE 5: Corneal Foreign Body

CPT / ICD
–
–
–
–
99213-25 / Abrasion (918.1) = $50.00
99285 / Abrasion (918.1) = $45.00
65222 / Corneal Foreign Body (930.00) = $65.00
Total $ 160.00
Rx: Acular LS QID / Zymar QID / Patch +/- Ibuprofen
400mg
 RTO: 1 Day

JAM
CASE 6: Misdirected Lashes

CPT / ICD
–
–
–
–
99213-25 / SPK (370.21) = $50.00
92285 / SPK (370.21) = $45.00
67820/ Trichiasis (374.05) = $45.00
Total $140.00
Rx: Xibrom BID / AFTs
 RTO: 1 Day / PRN

JAM
CASE 7: Corneal Erosion

CPT / ICD
–
–
–
99213 / Recurrent Corneal Erosion (371.42) = $50.00
92070 / Recurrent Corneal Erosion (371.42) = $70.00
Total $120.00
Rx: Vigamox TID / Nevanac TID / Bandage SCL
 RTO: 1 Day
 CPT / ICD

–
–
99212 or 92012 / Recurrent Corneal Erosion (371.42) =
$45.00 or $63.00
Total $165.00 or $183.00
JAM
CASE 8: Bacterial Keratitis

CPT / ICD
–
–
–
99213 or 92012 / Bacterial Keratitis (370.03) = $50.00 or
$63.00
92285 / Bacterial Keratitis (370.03) = $45.00
Total $95.00 or $108.00
Rx: Zymar q2h
 RTO: 1 Day
 E/M: 99212 or 99213 or…..?

–
Total $145.00 and up
JAM
CASE 9: Central Serous Retinopathy

CPT / ICD
–
–
–
–
99213 / Central serous retinopathy (362.41) = $50.00
92225-LT / Central serous retinopathy (362.41) = $20.00
92250 / Central serous retinopathy (362.41) = $70.00
Total $140.00
Rx: Observation RTO: 1 Mos
 CPT / ICD

–
–
–
–
99213 / Central serous retinopathy (362.41) = $50.00
92226-LT / Central serous retinopathy (362.41) = $20.00
92135-LT / Central serous retinopathy (362.41) = $45.00
Total $255.00
JAM
CASE 10: Macular Degeneration

CPT / ICD
–
–
–
–
99203 / Age Related Macular Degeneration (362.51) = $95.
92225-RT, 92225-LT / (362.51) = $40.00
92250 / (362.51) = $70.00
Total $205.00
Rx: Amsler Grid / Vitamins
 RTO: 6 Mos
 CPT / ICD

–
–
99212 / 92135-RT, 92135-LT / (362.51) = $135.00
Total $340.00
JAM
CASE 11

CPT / ICD
–
–
–
–
99213 / Rheumatoid Arthritis (714.0), High Risk Medical
Treatment (V58.69) = $50.00
92226-RT, 92226-LT / (714.0, V58.69) = $40.00
92083 / (714.0, V58.69) = $70.00
Total $160.00
Rx: Observation
 RTO: 6 Mos
 CPT / ICD

–
–
Same as above = $160.00
Total $320.00
JAM
CASE 12

CPT / ICD
–
–
–
99213 or 92012 / Dermatitis (373.32) = $50.00 or $63.00
92285 / (373.32) = $45.00
Total $95.00 or $108
Hydrocortisone 1.0% QID / Cold Packs
 RTO: 1 WK
 CPT / ICD

–
–
99212 / (373.32) = $45.00
Total $140.00 – $153.00
JAM
CASE 13: Glaucoma Suspect

CPT / ICD
–
–
–
–
–

CPT / ICD
–
–
–


99214 / Glaucoma Suspect (365.01) = $80.00
92020 / (365.01) = $25.00
76514 / (365.01) = $15.00
92250 / (365.01) = $70.00
92083 / (365.01) = $70.00
99213 or 92012 / (365.01) = $50.00 or $63.00
92235-RT, 92235-LT / (365.01) = $90.00
Total $400.00 or $413.00
Rx: Initiate or continue treatment or consultation-MD
Use V58.69 in addition to ICD code when changing medications
in a glaucoma patient
JAM
CASE 14
Dx: Documentation: Narrative & Shirmer Strips
 CPT / ICD Temporary Collagen Plugs

–
–
–
–

99214-25 / Dry Eye Syndrome (370.33) = $80.00
68761-E2 / (370.33) = $125.00
68761-E4 / (370.33) = $125.00 (Paid at 50% allowable)
Total $267.00
E/M: Permanent Silicone Plugs
–
99212-25, 68761-E2, 68761-E4 / (370.33) = $227.00
RTO: >10 Days After Permanent Punctal Occlusion
 Total $494.00

JAM
CASE 15

CPT / ICD
–
–
–
66984-55, RT / 366.16
Date of Service-is date of surgery
Range Dates-starts on date of transfer of care from MD to
OD, ends 90 days from date of surgery
Rx: Post-Operative Care
 RTO: Outcome dependant
 E/M: 92015 and Material/Hardware Codes (DME)

JAM
Monitor Compliance with Audits


Develop a “Documentation”
team
Monthly Assessment
–

Report your Results
–

10 charts/Provider
All staff, residents, students
Acknowledge positive &
negative variances
–
RETRAIN, RETRAIN..
THANK YOU!

Primary Eyecare Network
–
1.800.444.9230
www.primaryeye.net
–
Medicare Compliance Kit
 Health
History Questionnaire
 Examination Forms
 E/M Worksheets
 ICD-9 Codes
 Interpretation/Report form
–
Medicare A-Z Manual
–
Superbills / Signature on File stickers / Electronic Claims
–
HIPAA Compliance Manual
JAM
Thank you
Missouri Eye Associates
McGreal Educational
Institute
Excellence in Optometric Education