Understanding Medicare
Guidelines - 2013
John A. McGreal Jr., O.D.
Missouri Eye Associates
McGreal Educational Institute
Excellence in Optometric Education
John A. McGreal Jr., O.D.
McGreal Educational Institute
Missouri Eye Associates
 11710 Old Ballas Rd.
 St. Louis, MO. 63141
 314.569.2020
 314.569.1596 FAX
 mcgrealjohn@gmail.com
JAM
2013 Medicare E/M Guidelines
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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 Implement a Compliance Plan
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Medicare Part B Deductible
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Deductible (Medicare Part B)
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Will increase to $147 in 2013 ($7 more);
thereafter increase by annual percentage increase in Part B
expenditure
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2006 New ICD-9 Codes
Code first diabetes (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
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Must report with ICD code for diabetic retinopathy
 362.01
= background diabetic retinopathy
 362.02 = proliferative diabetic retinopathy
 362.03 – 362.06
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Timely Claims Submission
Affordable Care Act reduced the maximum time
period for submission of Medicare fee-for-service
claims to one calendar year after the date of service
 This change applies to services furnished after
January 1, 2010
 Reduces the previous maximum timely filing
deadline of 15-27 months
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2011 New CPT Codes
66761 – Iridectomy/iridotomy by laser surgery per
session (instead of one or more, with GD010)
 67220 – Destruction of localized lesion of choroid (ex.
Choroidal neovascularization); photocoagulation, one or
more sessions
 0191T – Insertion of ant. segment drainage device,
without extraocular reservoir, internal approach into TM
 0253T – Insertion of ant. segment drainage device,
without extraocular reservoir, internal approach, into SC
 0192T – Insertion of anterior seg aqueous drainage
device, without extraocular reservoir, external approach
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Ex. EXPRESS Implant
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New CPT Codes Scanning laser LCD
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92133 or 92134 and fundus photography are
mutually exclusive in CCI edits
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CCI assigned an indicator of “1” instead of “0” which
means there may be medical indications where it is
appropriate to unbundle the two codes
There are a limited number of clinical conditions
where both techniques are medically necessary and
reasonable on the ipsilateral eye
 In these situations, both CPT codes may be reported
appending the modifier -59 to CPT code 92250
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2012 Deleted CPT Codes
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92120 – Tonography with I&R, perilimbal suction
method
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92130- Tonography with water provocation
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92070 – Fitting of Contact lens for treatment of
disease, including supply of lens
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2012 New CPT Codes
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92071 – Fitting of Contact Lens for Treatment of
Ocular Surface Disease
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Do not report with 92072
Report supply of lens separately with 99070 or
appropriate supply code
92072 – Fitting of Contact Lens for Management of
Keratoconus, initial fitting
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For subsequent fittings, use E/M services or general
ophthalmic services (92xxx)
Do not report with 92071, report supply codes separately
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2012 New ICD-9 Codes
379.27 Vitreomacular adhesions, associated with
AMD, DR, PVD
 V19.11 Family history of glaucoma
 V19.19 Family history of other specified eye
disorder
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2012 New ICD-9 Glaucoma Coding
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Given great variability of cost of care & resource
utilization among glaucoma patients, glaucoma care
has been targeted for use of potential value-based
modifiers in the future
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ICD-9 and ICD-10 codes reflect this and will allow
stratification of a patient population
Developed by the American Glaucoma Society
(AGS) workgroup, including Drs. Fellman & Mattox
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Then enlisted comprehensive ophthalmologists,
optometrists, and a few glaucoma specialists to evaluate
and test for accuracy using real cases from Dr. J. Stein at
University of Michigan
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2012 New ICD-9 Codes – Glaucoma Stages
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When coding glaucoma subcategories 365.1-365.6
assign an additional code to identify specific stage of
glaucoma (365.7)
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365.70
365.71
365.72
365.73
365.74
Glaucoma stage, unspecified
Mild stage glaucoma
Moderate stage glaucoma
Severe stage glaucoma
Indeterminate stage glaucoma
Includes sequencing instructions to code first the
glaucoma, by type
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Report new V19.11 history codes where appropriate
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Step One: Code by Type
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Only the codes listed here require add-on staging codes
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365.10 Open angle glaucoma, unspecified
365.11 Primary open angle glaucoma
356.12 Low tension glaucoma
365.13 Pigmentary glaucoma
365.20 primary angle closure glaucoma, unspecified
365.23 Chronic or primary angle closure glaucoma, unsp
365.31 Steroid induced glaucoma
365.52 Pseudoexfoliation glaucoma
365.62 Glaucoma associated with ocular inflammations
365.63 Glaucoma associated with vascular disorders
365.65 Glaucoma associated with ocular trauma
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Step Two: Add Stage
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Determine severity of glaucoma in worse eye
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365.71 Mild (disc abnormalities consistent w glaucoma but
no VFD on SAP or Short wave-length doubling perimetry)
365.72 Moderate stage (Disc abnormalities consistent w
glaucoma and VFD in 1 hemifield, not w/in 5 degrees of fix)
365.73 Severe stage (Disc abnormalities consistent w
glaucoma VFDs in both hemifields, and/or loss w/in 5
degrees of fix in at least 1 hemifield)
365.74 Indeterminate (VFs not performed yet, or patient
incapable of VF testing or unreliable or uninterpretable VFs)
365.70 Unspecified, stage not recorded in chart
Compliance requires documentation of stage in medical
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record
Additional Glaucoma Code Changes
365.01 Open angle suspect, Low Risk (1-2 risk factors)
 365.05 Open angle suspect, High Risk (3+ risk factors)
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Risk factors – family history, race, elevated IOP, disc
appearance and thin central corneal thickness
365.02 Primary angle closure suspect (anatomical
suspect, narrow angle)
 365.06 Primary angle closure without glaucoma damage
(defined as angle damage such as synechia or high IOP,
but w/o optic nerve damage)
 365.23 Chronic angle closure glaucoma (angle damage
plus optic nerve damage)
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2012 SCODI Update
Medicare carriers have updated their Local Coverage
Decisions (LCDs) for scanning computerized digital
ophthalmic imaging (SCODI) to include covered
diagnosis codes for diagnostic screening of patients
taking Hydroxychloroquine (Plaquenil).
 Some indicate frequency and some specify spectral
domain only
 Covered ICD-9 codes are V58.69 High Risk
Medications, Current use, and V67.51, Following
Completed Treatment with High Risk Medications
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2013 Other Changes
Cataract surgery fees reduced for 66982 & 66984 by
13%
 Physician Compare Website – includes name,
specialty, education, participation status, status in
PQRS & e-prescribing, board certification,
additional foreign language, hospital affiliation, EHR
incentive program
 ICD-9 – NO CHANGES!
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Physician Value-Based Payment Modifier
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CMS will adjust payment to some physicians based
on quality & resource use beginning in 2015 and all
physicians by 2017
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Now applies only to groups of 100 or more (originally 25)
Smaller groups (2-99) remain unaffected until 2017
3% payment penalty to hospitals began in 2012 for
re-admission rates higher than national average
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Heart failure
Pneumonia
Myocardial infarction
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Reduction in Diagnostic Testing
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CMS will decrease payment by 20% of technical
component of second and subsequent diagnostic tests
furnished by same physician (or physicians in same
group) to same patient on same day
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Originally set at 25%
A diagnostic service refers to any diagnostic test that has
a technical & professional component
CMS indicated they will closely monitor practice
changes to bypass multiple payment reductions
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Reduction in Diagnostic Testing
76510
 76511
 76512
 76513
 76514
 76516
 76519
 92125
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92060
92081
92082
92083
92132
92133
92134
92136
92228
92235
92240
92250
92270
92275
92283
92284
92285
92286
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PQRI Name Change to PQRS
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CMS continues incentive payments in 2013
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www.cms.gov/PQRI/15_MeasuresCodes.asp
Successful PQRS reporters earn 0.5% in 2013
 Must report on at least 3 measures 50% of the time
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Decrease from 80% in 2010
Report for full year (Jan1-Dec31, 2013)
 Incentive payments for years 2014 will be 0.5%
 2015
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PQRS 2013
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In 2015 a 1.5% PQRS payment penalty will be
applied, in 2016 this increases to 2.0%
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2013 PQRS participation used to determine cuts in 2015
Participation means attempting to report at least one PQRS
measure between Jan 1 –Dec 31 2013
Glaucoma staging codes removed
 Measure 124: Health Information Technology has been
eliminated
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OIG Audits / Work Plan
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Ophthalmological services – 92xxx codes
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E/M Services: Use of modifiers
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Reviewing claims during 2011
6.8 billion in claims by eye MDs & ODs
Focus on 92004/92014, other 92- included
Modifiers -25
Bilateral intravitreal injections
Sequestration – 2% payment reductions across the board
in Medicare claims beginning April 1, 2013
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Includes a 2% reduction in EHR incentive bonus
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OIG Work Plan
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Ophthalmological services – New
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E/M Services: Use of modifiers
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Reviewing claims during 2011
$6.8 Billion paid to ophthalmologists & optometrists in 2011
8.31% of all claims paid to all physicians in all specialties
92004 was 12th highest paid code used in all specialties
66984 was 5th highest paid code
99xxx E&M codes not included, not specialty specific
Modifiers -25
Bilateral intravitreal injections
http://oig.hhs.gov/reports-andpublications/archives/workplan/2013/Work-Plan-2013.pdf
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OIG Work Plan
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Rank
5
12
26
31
52
63
67
73
103
141
148
178
CPT
66984
92014
92012
92135
92004
66984
00142
92083
92250
67228
15823
92136
Services
Cat-IOL
Comp eye exam, est pt
Interm eye exam, est pt
Scanning laser
Comp eye exam, new pt
Cat-IOL, complicated
Anesthesia for proc, eye, lens
Visual field, full
Fundus photography
Treatment of exten or prog retinopathy
Blepharoplasty
Ophthalmic biometry w IOL power calc
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Recovery Audit Contractors RAC
Evaluating RAC performance 2010 & 2011
 Completed 3 year demonstration project in 2012
 Congress will mandate a nationwide implementation of
a permanent RAC program for Medicare part A & B
 Mandates by Tax Relief & Health Care Act 2006 and
Affordable Care Act
 Tool used include comparative billing reports
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Shows specific provider billing patterns compared to peers
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Health Insurance Portability and
Accountability Act of 1996
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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
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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
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Qui Tam Relaters
Amendment to False Claims Act of 1986
 Encourages private individuals to sue in the
government’s behalf
 Whistleblowers - 30% of recoveries
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$1 Billion paid since 1987 in Qui Tam actions
Compliance Plan
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Eliminates aggressive or conservative billing philosophies
Removes incentives for whistleblowers
Improves collections while reducing audit risks
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Top 10 Procedure Codes – Optometry
Missouri / Jan-June 2007 / 495 Providers
92014
 99214
 92004
 92012
 99213
 66984
 92250
 92083
 99203
 92135
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$1,369,645
$ 634,210
$ 562,906
$ 551,297
$ 541,616
$ 395,125
$ 339,862
$ 277,708
$ 199,510
$ 195,427
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2012 Comprehensive Error Rate Testing
(CERT)
There has been a HUGE increase in CERT audits of
E/M services since October 2011
 From April 2009-May 2010, E/M services accounted
for 28 billion in Medicare Part B payments
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Estimated 8.4% billed incorrectly
Providers encouraged to review 1997 E/M
Guidelines for compliance
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2011 CMS Optometry Probe Results
Prepayment review of 100 services from 100 claims
 Probe: CPT 99213 (random)
 Results
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66% allowed as billed
34% denied
 23%
No documents submitted
 5% Services not documented in medical record
 3% Non-covered services
 3% Not medically necessary
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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 (Implementation of ICD-10 is October 1,
2014!!)
 ICD-9-CM (Volume 3): inpatient disease codes
 NDC: National Drug Code
 HCPCS: Healthcare Common Procedure Coding
System
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Medicare – Just Give Me The Numbers
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Longevity Revolution
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47, 672,971 Medicare beneficiaries in US
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First year of Baby Boomers hitting 65 years of age
10,000/day turn 65 years of age
An individual turns 60 years of age every 8 seconds
If you live until age 65, average life expectancy is age 84
15% of total population
Cataract surgery is the most common surgical
procedure in US in Medicare beneficiaries
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Also boasts best outcomes
Lowest complication rate
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Medicare – Distribution by Age (2004)
65-69
 70-74
 75-79
 80-84
 85+
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23.2 %
19.9 %
17.3 %
12.9 %
11.0 %
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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
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INTRODUCTION
CMS
 CPT
 ICD
 Medicare
 Major Medical
 E/M Coding (99XXX)
 Eye Coding (92XXX)
 Special Ophthalmic Codes
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E/M GUIDELINES
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New/Established Patient
Chief Complaint
History of Present Illness
Family History
Past History
Social History
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New additions level of education, sexual history, marital status/living
arrangements
Review of Systems
Time
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E/M DESCRIPTORS
History *
 Examination*
 Medical Decision Making*
 Counseling
 Coordination of Care
 Nature of the Presenting Problem
 Time
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CATEGORIES OF SERVICE
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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)
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ELIMINATED for Medicare, Medicaid, Tricare and
Medicare Advantage HMOs and when any of these are
secondary payors
Can still be used for other commercial plans
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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
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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
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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
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DOCUMENTATION OF HISTORY
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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)
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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)
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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
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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)
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# Dx / Rx Options - Ext / Data - Ext / Risk - High
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Comprehensive Ophthalmological Service
92004 / 92014
Complete system evaluation,
 Need not be performed at one session
 Integrated services where med decision making cannot
be separated from examination methods
 Itemization of service components, such as slit lamp
examination, keratometry, routine ophthalmoscopy
retinoscopy, tonometry, or motor evaluation is not
applicable
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Comprehensive Ophthalmological Service
92004 / 92014
Includes history, medical observation, external &
ophthalmoscopic examinations, gross visual fields,
sensorimotor examination
 Often includes, as indicated: biomicroscopy,
examination with cycloplegia or mydriasis and
tonometry
 Always includes initiation of diagnostic and treatment
programs
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Comprehensive Ophthalmological
Service
92004/92014
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Always includes initiation of diagnosis and treatment
programs
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includes the prescription of medication, and arranging for
special ophthalmological diagnostic or treatment services,
consultations, laboratory procedures and radiological services
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Intermediate Ophthalmological Service
92002 / 92012
Evaluation of new or existing condition, complicated
with a new diagnostic or management problem not
necessarily relating to the primary diagnosis
 Integrated services where med decision making cannot
be separated from examination methods
 Includes history, medical observation, external &
adnexal, & other diagnostic procedures as indicated;
may include use of mydriasis for ophthalmoscopy
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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
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HCPCS “S” Codes
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S0620
Routine ophthalmologic exam including
refraction; new patient
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S0621
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S0625
Routine ophthalmologic exam including
refraction; established patient
Digital screening retina
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2013 Medicare Physician Fee Schedule
Physicians faced a 26.5% cut in payment effective
January 1, 2013 based on Sustainable Growth Formula
 American Taxpayer Relief Act of 2013 – signed into law
on January 2, 2013
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Prevented negative fee update
0% update until 12/31/13
Contractors may hold claims with January 2013 dates for 10
days
Carriers to post MPFS on websites by January 23, 2013
This is the 12th time the SGF resulted in a payment cut,
although all have been averted by Congress except 2002
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2013 Medicare Fee Schedule
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99201
 99202
 99203
 99204
 99205
$ 43.03
$ 73.21
$ 106.51
$ 162.50
$ 201.26
99211
99212
99213
99214
99215
$ 19.93
$ 43.03
$ 71.76
$ 105.16
$ 140.81
92002
 92004
$ 81.34
$ 148.59
92012
92014
$ 85.66
$123.76
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Refraction
92015
Non-covered service
 Can be billed to beneficiary
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failure to do so results in lost revenues
Reminders
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Charge only for “Rx-able” refractions
Do not forget to charge for the final refraction when changing
spectacles in a post-operative cataract patient
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Gonioscopy
92020
Bilateral
 Requires documentation
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describe visible angle structures
No limitations to diagnostic groups in most states
 Fee
$ 27.12
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Visual Field 9208x
Bilateral
 Requires Interpretation
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separate report form
narrative in body of medical record, on date of service
Fee (-81) / $ 34.29
 Fee (-82) / $ 49.20
 Fee (-83) / $ 65.03
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Extended Ophthalmoscopy
92225 / 92226
Unilateral
 Initial (-225) vs. Subsequent (-226)
 Implies detailed, extra ophthalmoscopy
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document fundus lenses used
Modifiers RT /LT
 Requires retinal drawings & interpretation
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sizes, colors and dimensions carrier specific
Fee 92225 ($ 27.13) 92226 ($ 24.38)
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Fundus Photography
92250
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Bilateral
Not Bundled
Requires Interpretation
Fee $ 69.81
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External Ocular Photography
92285
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Report for documentation of medical progress
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Ex.: close-up photography, slit lamp photography,
goniophotography, stereo-photography
Bilateral
 Not Bundled
 Requires Interpretation and report
 Fee
$ 20.79
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Special Anterior Segment Photography
92286
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With specular endothelial microscopy and cell count
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Ex: Konan specular microscope
Bilateral
 Not Bundled
 Requires Interpretation and report
 Fee
$ 37.95
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Special Anterior Segment Photography
92286
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364.00-364.04 iridocyclitis
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
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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
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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
379.33 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
Tear Osmolarity Testing
83861

Unilateral
–

Paired or cross walked to code 84081
Applies to TearLab’s Osmolarity Device
–
–
–
–
Novel “Lab-on-a-chip”
Point of care, 50nl sample of tear fluid
Sample-to-answer in less than 30sec
CLIA waiver granted
Requires Interpretation & report
 Fee
$23.25

JAM
Computerized Corneal Topography
92025
Bilateral or unilateral
 Requires interpretation & report
 No limitations to diagnostic groups in most states
 Fee
$ 37.56

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
Scanning Computerized Ophthalmic
Diagnostic Imaging
92132
Unilateral or bilateral
 Applies to anterior segment evaluations

–
–
Carl Zeiss / Optical Coherence Tomography (Cirrus)
Optovue / (RTVue, iVue)
Requires Interpretation & report
 Fee
$ 35.66

JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging 92132










190.0, 190.3 Malig neoplasm of eyeball, ecept conj, cornea,
retina or choroid
190.3 malignant neoplasm of conjunctiva
190.4 Malignant neoplasm of cornea
190.6, 190.8 Malignant neoplasm of choroid, other sites
224.0 Benign neoplasm of eyeball except conjunctiva, cornea,
retina, or choroid
224.3 Benign neoplasm conjunctiva
224.4 Benign neoplasm of cornea
224.6, 224.8 Benign neoplasm of choroid, other sites
360.51 Foreign body in anterior chamber (magnetic)
360.61 Foreign body in anterior chamber
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging 92132











364.51 Essential iris atrophy
364.53 Pigmentary iris degeneration
364.54 Degeneration of pupillary margin
364.71 Posterior synechia
364.72 Anterior synechia
364.75 Pupillary abnormalities
364.76 Iridodialysis
364.77 Recession of chamber angle
364.82 Plateau iris syndrome
365.02 Anatomical narrow angle
365.20-365.89 Primary angle closure and other glaucomas
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging 92132











366.16 Nuclear sclerosis
370.00-370.07 Corneal ulcers
371.00-371.09 Corneal opacities
371.20-371.24 Corneal edema (includes due to CL)
371.57 Endothelial dystrophy
372.40-372.45 Pterygium
379.31 Aphakia
379.32 Subluxed lens
996.51 Mechanical complication of corneal graft
996.53 Mechanical complication of ocular lens prosthesis
996.69 Infection & Inflammation due to other int prosthetic
JAM
device implant or graft
Fitting CL for Ocular Surface Disease
92071
Unilateral; Use –RT/-LT or -50
 Do not report 92071 in conjunction with 92072
 Report supply of lens separately with 99070 or
appropriate supply code
 Fee
$33.65

JAM
Fitting CL for Management Keratoconus
92072

Initial fitting
–
For subsequent fittings, report E/M services or general
ophthalmological services
Do not report 92072 in conjunction with 92071
 Report supply of lens separately with 99070 or
appropriate supply code
 Unilateral payment; Use –RT/-LT or -50
 Fee
$126.11

JAM
Serial Tonometry
92100
Bilateral
 Requires Interpretation & Report

–
–

Example: Angle closure glaucoma
multiple measurements over time
Fee
$ 79.89
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
$ 14.39

JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging
92133


Unilateral or bilateral
Applies to glaucoma or optic nerve evaluations
–
–
–
–


Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis)
Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)
Optovue / (RTVue, iVue)
Marco / Retinal Thickness Analyzer (RTA)
Requires Interpretation & report
Fee
$ 44.37
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92133










360.30-360.34 Hypotony and flat chamber
354.22 Glaucomatocyclitic crises
365.00-365.04 Glaucoma suspect, OCHTN
365.10-365.15 Open angle glaucoma
365.20-365.24 Primary angle closure glaucoma
365.31-365.32 Steroid induced glaucoma
365.41-365.44 Glauc w chamber anomalies
365.51 Phakolytic glaucoma
365.52 Pseudoexfoliation glaucoma
365.59 Glaucoma assoc w lens disorders
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92133










365.60-365.65 Glaucoma assoc w ocular trauma
368.40-368.45 Visual field defects
376.00-376.9 Acute inflammations of the orbit
377.00-377.03 Papilledemas
377.04 Foster-Kennedy
377.10 Optic atrophy
377.14-377.16 Glaucomatous atrophy
377.21 Drusen
377.22 Crater like holes of optic disc
377.23 Coloboma of optic disc
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92133
377.24 Pseudopapilledema
 377.41-377.49 Ischemic optic neuropathies
 377.51-377.54 Disorders of optic chiasm assoc w pit
neoplasms or inflammatory disorders
 377.61-377.63 Disorders of other visual pathways assoc
w neoplasms or inflammations
 743.20-743.22 Buphthalmos
 743.57-743.58 Cong anomalies of optic disc & vasc
anomalies

JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging
92134


Unilateral or bilateral
Applies to retinal evaluations
–
–
–
–


Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis)
Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)
Optovue / (RTVue, iVue)
Marco / Retinal Thickness Analyzer (RTA)
Requires Interpretation & report
Fee
$ 45.35
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92134










190.6, 190.8 Malignant neoplasm choroid
224.6, 224.8 Benign neoplasm choroid or other sites
360.11 Sympathetic uveitis
360.21 Progressive high (degenerative) myopia
360.30-360.34 Hypotony, flat chamber
361.00-361.07 Retinal detachments
361.10 Retinoschisis
361.2 Serous retinal detachment
361.81 Traction detachment
362.01-362.06 Diabetic retinopathy, background to severe NPD
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92134









362.07 Diabetic macular edema
362.10-362.18 BDR, retinal vasculitis
362.31-362.32 Central or branch retinal artery occlusion
362.35-362.37 Central or branch retinal vein ooclusion
362.40-362.43 Retinal layer separation, hemor detach RPE
362.50- 362.77 Macular degeneration, retinal dystrophies
involving Bruch's membrane
362.81 Retinal hemorrhage
362.82 Retinal exudates and deposits
362.83 Retinal edema
JAM
Scanning Computerized Ophthalmic
Diagnostic Imaging - 92134











363.00-363.08 Focal chorioretinitis
363.10-363.15 Disseminated chorioretinitis
363.20-363.35 chorioretinitis unspecified
363.43 Angioid streaks
363.61 Choroidal hemorrhage
363.63 Choroidal rupture
363.70-363.72 Choroidal detachmts
376.00-376.9 Acute inflammations of orbit
379.11-379.19 Scleral ectasia and other scleral disorders
379.21-379.29 Vitreous degenerations & other disor of vitreous
921.3 Contusion of eyeball
JAM
Correction Trichiasis
67820*
Epilation
 By forceps
 ICD-9

–
–
374.05 Trichiasis without entropion
374.01 Senile entropion
Global days - 000
 Fee
$ 51.75

JAM
Removal of Foreign Body
65205*

External Eye, Conjunctiva
–
–

superficial
scleral, non-perforating
ICD-9
–
930.18 FB in cul-de-sac
Global days - 000
 Fee
$ 56.97

JAM
Removal of Foreign Body
65210*

External Eye, Conjunctiva
–
–
–

embedded (includes concretions)
subconjunctival
scleral, non-perforating
ICD-9
–
930.18 FB in other sites or combined sites
Global days - 000
 Fee
$ 70.31

JAM
Removal of Foreign Body
65222*

External Eye, Corneal
–

with Slit Lamp
ICD-9
–
930.0 FB in cornea
Global days - 000
 Fee
$ 69.04

JAM
Sensorimotor Examination
92060

Quantitative measurement of ocular deviation
–
document all major fields of gaze
Bilateral
 Requires interpretation and report
 Fee
$65.27
 92065 – Orthoptic and / or pleoptic training, with
continuing medical direction and evaluation
 Fee
$ 53.98

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 $ 128.04
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
$151.71

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
52 Reduced service
JAM
Comanagement of Surgery









Procedures / 66984 / $ 658.82
Global Periods - 90 days
Value - up to 20%
MD name and NPI
Modifiers (-54 on MD claim, -55 on OD claim and RT/LT)
Range Dates – from transfer date to end of 90 day global
Rules - Medicare Transfer Agreement in MD record
Correspondence
Legal/Political/Inter-professional Issues
JAM
Complicated Cataract Surgery
66982
New CPT code for 2001 / $ 818.06
 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 Studies for Clinical
Correlation
CASE 1: Cataract

CPT / ICD
–
–
–
92015 / Myopia (367.1) = $20.00
99203 / Cataract (366.16) = $100.00 or 92004 ($135)
Total $120.00 or +
Rx: Spectacles
 RTO: 1YR
 CPT / ICD

–
–
–
92015 / Myopia (367.1) = $20.00
99214 / Cataract (366.16) = $100.00 or 92014 ($110)
Total $120.00 or +
JAM
CASE 2: Blepharoconjunctivitis

CPT / ICD
–
99213 or 92012 / Blepharitis (373.00) = $60.00 or $75.00
Rx: Bacitracin Oint hs / Tobradex qid / Lid Hygiene /
AFTs
 RTO: 1 WK
 CPT / ICD

–
–
99212 / Blepharitis (373.00) = $40.00
Total $100.00 or $115
JAM
CASE 3: Allergic Conjunctivitis

CPT / ICD
–
–
99213 or 92012 / Conjunctivitis allergic (372.14)
$60.00 or $75.00
Rx: Pataday QD / Cold Packs / AFTs
 RTO: 1 WK
 CPT / ICD

–
–
99212 or 92012 / Conjunctivitis, allergic (372.14) = $40.00
or $75.00
Total $100.00 or $150.00
JAM
CASE 4: Rosacea (Skin & Eye)

CPT / ICD
–
–
–
99213 or 92012 Meibomianitis (373.12) / Acne Rosacea
(695.30) = $60.00 or $75.00
92285 / (370.01) Marginal keratitis = $25.00
Total $ 85.00 or $100.00
Rx: Zylet QID / Lid Hygiene (foams) / Doxycycline 50mg
BID / MetroCream 0.75% BID RTO: 2 D
 CPT / ICD

–
–
99212 or 99213 / Meimbomianitis (373.12) = $40.00 or $75.00
Total $125.00 or 175.00
JAM
Case 5 : Conjunctival Foreign Body

CPT / ICD
–
–
–
–
99213-25 / SPK (370.21) = $60.00 or 92012 ($75)
92285 / SPK (370.21) = $25.00
65210 / Conj FB (931.8) = $65.00
Total $150.00 or $165
Rx: Acular QID / AFTs / Besivance TID
 RTO: 1 Day / PRN

JAM
CASE 6: Corneal Foreign Body

CPT / ICD
–
–
–
–
99213-25 / Abrasion (918.1) = $60.00 or 92012 ($75)
99285 / Abrasion (918.1) = $25.00
65222 / Corneal Foreign Body (930.00) = $70.00
Total $ 155.00 or $170
Rx: Acular LS QID / Zymar QID / Patch +/- Ibuprofen
400mg
 RTO: 1 Day

JAM
CASE 7: Misdirected Lashes

CPT / ICD
–
–
–
–
99213-25 / SPK (370.21) = $60.00 or 92012 ($75)
92285 / SPK (370.21) = $25.00
67820/ Trichiasis w/o entropion (374.05) = $50.00
Total $135.00 or $150
Rx: Bromday qd / AFTs
 RTO: 1 Day / PRN

JAM
CASE 8: Corneal Erosion

CPT / ICD
–
–
–
99213 / Recurrent Corneal Erosion (371.42) = $60.00
92071 / Recurrent Corneal Erosion (371.42) = $70.00
Total $130.00
Rx: Vigamox TID / Nevanac TID / Bandage SCL /
Doxycycline 50mg qd optional / FreshKote TID
 RTO: 1 Day
 CPT / ICD

–
–
99212 or 92012 / Recurrent Corneal Erosion (371.42) =
$40.00 or $75.00
Total $170.00 or $205.00
JAM
CASE 9: Bacterial Keratitis

CPT / ICD
–
–
–
99213 or 92012 / Bacterial Keratitis (370.03) = $60.00 or
$75.00
92285 / Bacterial Keratitis (370.03) = $25.00
Total $85.00 or $100.00
Rx: IQUIX q2h
 RTO: 1 Day
 E/M: 99212 or 99213 or…..? Can add anterior OCT

–
Total $145.00 and up
JAM
CASE 10: Central Serous Retinopathy

CPT / ICD
–
–
–
–
99213 / Central serous retinopathy (362.41) = $60.00
92225-LT / Central serous retinopathy (362.41) = $20.00
92250 / Central serous retinopathy (362.41) = $70.00
Total $150.00 (Option to do OCT and use -59 on photo*)
Rx: Observation or Bromday qd RTO: 1 Mos
 CPT / ICD

–
–
–
–
99213 / Central serous retinopathy (362.41) = $60.00
92226-LT / Central serous retinopathy (362.41) = $20.00
92134 / Central serous retinopathy (362.41) = $50.00
Total $270.00
JAM
CASE 11: Epiretinal Membrane

CPT / ICD
–
–
–
–
99214 / Macular puckering (362.56) = $60.00
92225-LT / Macular puckering (362.56) = $20.00
92250 / Macular puckering (362.56) = $70.00
Total $160.00 (Option to do OCT and use -59 on photo)*
Rx: Observation RTO: 1 Mos
 CPT / ICD

–
–
–
–
99213 / Macular puckering (362.56) = $60.00
92226-LT / Macular puckering (362.56) = $20.00
92134 / Macular puckering (362.56) = $40.00
Total $280.00
JAM
CASE 12: Macular Degeneration/Dry

CPT / ICD
–
–
–
–



99203 / Age Related Macular Degeneration (362.51) = $100.
92225-RT, 92225-LT / (362.51) = $40.00
92250 / (362.51) = $70.00
Total $210.00
Rx: Amsler Grid (or PHP) / MPOD (cash) / Vitamins (Cash) /
Genetic testing to set risk (Information and frequency issues)
RTO: 6 Mos or sooner
CPT / ICD
–
–
99213 / 92134 / (362.51) = $100.00
Total $310.00 plus MPOD and Vitamins
JAM
CASE 13: Macular Degeneration/Wet

CPT / ICD
–
–
–
–



99203 / Age Related Macular Degeneration (362.52) = $100.
92225-RT, 92225-LT / (362.52) = $40.00
92250 / (362.51) = $70.00
Total $210.00 (Option for OCT use -59 on photo)*
Rx: Amsler Grid (or PHP or PHP Home) / MPOD (cash) /
Vitamins / Consult Retina for IVFA and treatment
RTO: 6 Mos
CPT / ICD
–
–
99213 / 92134 / 92082 (PHP) /(362.52) = $150.00
Total $360.00 insurance plus MPOD testing and Vitamin sales
JAM
CASE 14: High Risk Medications

CPT / ICD
–
–
–
–
–



99213 / Rheumatoid Arthritis (714.0), High Risk Medical Treatment
(V58.69) = $60.00
92226-RT, 92226-LT / (714.0, V58.69) = $40.00
92083 / (714.0, V58.69) = $70.00
92134 / (V58.69) = $45
Total $215.00
Rx: Observation
RTO: 6 Mos
CPT / ICD
–
–
Same as above = $215.00 (some carriers allow SD-OCT once per year)
Total $430.00
JAM
CASE 15: Dermatitis

CPT / ICD
–
–
–
99213 or 92012 / Dermatitis (373.32) = $60.00 or $75.00
92285 / (373.32) = $25.00
Total $85.00 or $100
Hydrocortisone 1.0% QID / Cold Packs
 RTO: 1 WK
 CPT / ICD

–
–
99212 / (373.32) = $40.00
Total $125.00 – $140.00
JAM
CASE 16: Glaucoma Suspect

CPT / ICD
–
–
–
–
–

CPT / ICD
–
–
–



99214 / Glaucoma Suspect Low Risk (365.01) = $100.00 or 92014 ($110)
92020 / (365.01) = $25.00
76514 / (365.01) = $15.00
92250 / (365.01) = $70.00
92083 / (365.01) = $80.00
99213 or 92012 / (365.01) = $60.00 or $75.00
92133 / (365.01) = $50.00
Total $400.00 or $425.00
Dx: Complete testing battery in two visits
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 17: Neovascular glaucoma

CPT / ICD
–
–
–
92012 / Glaucoma assoc w vascular disorders (365.63 /
Severe stage 365.73) = $75.00
92132 / goniosynechia (364.73) = $35.00
Total $108.00
Rx: Combigan BID OS, PredForte BID OS
 RTO: 1 WK
 E/M: 99213 or….plus gonioscopy.?

–
Total $170.00 and up
JAM
CASE 18: Punctal Occlusion of Dry Eye
Dx: Documentation: Narrative & Shirmer Strips
 CPT / ICD Temporary Collagen Plugs

–
–
–
–

99214-25 / Dry Eye Syndrome (370.33) = $100.00
68761-E2 / (370.33) = $135.00
68761-E4 / (370.33) = $135.00 (Paid at 50% allowable)
Total $300.00
E/M: Permanent Silicone Plugs
–
99212-25, 68761-E2, 68761-E4 / (370.33) = $240.00
RTO: >10 Days After Permanent Punctal Occlusion
 Total $540.00

JAM
CASE 19: Cataract Co-Management
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CPT / ICD
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66984-55, RT or LT / 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
MD name and NPI
Rx: Post-Operative Care
 RTO: Outcome dependant
 E/M: 92015 and Material/Hardware Codes (DME)
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JAM
Monitor Compliance with Audits

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Develop a “Documentation”
team
Monthly Assessment
–

Report your Results
–

10 charts/Provider
All staff, residents, students
Acknowledge positive &
negative variances
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RETRAIN, RETRAIN..
THANK YOU!

Primary Eyecare Network
–
1.800.444.9230
–
Medicare Compliance Kit

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


www.primaryeye.net
Health History Questionnaire
Examination Forms
E/M Worksheets
ICD-9 Codes
Interpretation/Report form
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Medicare A-Z Manual
–
Superbills / Signature on File stickers / Electronic Claims
–
HIPAA Compliance Manual
PQRS Card
–
JAM
Compliance Specialists, Inc
Billing/Coding/Compliance specialists
 Audit help/Fee scheduling/Profiling
 Virtual billing service
 EyeComply Program

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–
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10 Chart review/audit
CPT code practice profile
10 Claims assistance
Builds compliance program
Helps with re-credentialling
Introducing ICD-10-CM
John A. McGreal Jr., O.D.
Missouri Eye Associates
McGreal Educational Institute
Excellence in Optometric Education
Understanding the Basics & Getting Ready
Differences between ICD-9 & ICD-10
 How the ICD-10CM is laid out
 How to Use the Alphabetic Index
 How to Use the Tabular List
 How to Use the Index of injuries
 How to Use the Table of Drugs & Chemicals
 How to Understand new Abbreviations
 How to Use Placeholders
 How to Use Code Extensions
 Understand laterality

JAM
The Lilliputians Take Control of the
Healthcare Giant
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ICD-9 has 13,000 codes
ICD-10 has 140,000
Effective date – October 1, 2013
Transition will be difficult as there is little in common
with our current coding paradigms
Requires doctors, not staff to do the specific coding
Every artery and nerve has been issued a number
Number of physicians = 800,000/ 35% own their own
practice (Source Accenture with data from Medical
Group management Assoc and AMA)
JAM
Introduction to ICD-10-CM

Clinical modification of WHO’s ICD-10
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Clinical emphasizes the intent to serve as a tool in
classification of morbidity data for indexing, medical
records care review, medical & ambulatory care
programs, health statistics
 Better
understand complications
 Better design robust algorithms
 Track outcomes
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To describe the “clinical” picture the codes must be
more precise
Far exceeds ICD-9 in number of concepts and codes
Disease classification expanded to include health
related conditions and provides greater specificity
JAM
Improvements Over ICD-9

Index MUCH longer
–
Ex 28 pterygium, 69 conjunctivitis, 12 astigmatism codes
Adds information relevant to ambulatory & MC
encounters
 Expanded injury codes
 Combination diagnosis/symptom codes
 Addition of 6th & 7th characters
 Incorporates common 4th & 5th digit subclassification
 Laterality
 Allows further expansion
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JAM
Organization of ICD-10-CM
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Alphabetical Index
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Alphabetical list of terms and corresponding codes
Index of Diseases & Injury
Table of Neoplasm
Table of Drugs & Chemicals
Index of External causes of injury
Tabular List
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Chronological list of codes
Divided into chapters
Based on body systems
JAM
Tabular List Detail
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Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Infectious and parasitic diseases
Neoplasms
Diseases of Blood and blood forms
Endocrine, nutritional, metabolic
Mental & behavioral
Nervous system
Eye & adnexa
Ear and mastoid
Circulatory system
Respiratory system
Digestive system
JAM
Tabular List Detail

Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
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Chapter 19
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Chapter 20
Chapter 21
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Skin & subcutaneous
Musculoskeletal
Gastrointestinal
Pregnancy & childbirth
Conditions of perinatal period
Congenital / Malformations
Signs/Symptoms/abnormal clinical
laboratory findings
Injury, Poisoning, consequences of external
causes
External causes of morbidity
Factors influencing health status & contact
JAM
with health services
Chapter 7: Diseases of Eye/Adnexa Detail
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H00-H05
H10-11
H15-H22
H25-H28
H30-H36
H40-H42
H43-H44
H46-H47
H49-H52
H53-H54
H55-H57
H59
Eyelid, lacrimal, orbit
Conjunctiva
Sclera, cornea, iris, ciliary body
Lens
Choroid/retina
Glaucoma
Vitreous & globe
Optic nerve & pathways
Ocular muscles, accomodation, refraction
Visual disturbances and blindness
Other disorders eye & adnexa
Intra-operative & post-procedural complicationsJAM
Format & Structure
Tabular list contains categories, subcategories & codes
 Characters may be letter or numbers
 Categories are 3 characters
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Character 1 is alpha
 All
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letter used except U
Character 2 is numeric
Character 3-7 are alpha or numeric
Use decimal after 3 characters
Subcategories are 4 or 5 characters
 Codes may be 3, 4, 5, 6 or 7 characters
 Laterality specific

JAM
Placeholder Characters
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Character “X” used as a placeholder
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Allows for future expansion
Where it exists it must be used to be valid
Ex S05.8x1A
JAM
Placeholder Characters

Code extensions (seventh character) have been added for
injuries and consequences of external causes (S00-T88),
to identify the encounter
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“A” Initial encounter – receiving active treatment
“D” Subsequent encounter-use after Pt received active treamt
“S” Sequelae-used for complications/conditions arise as result
of injury
S
only added to injury code, not sequela code
 Sequela code first, followed by injury code
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Ex: S30 superficial injury of abdomen
 S30.810,
code requires extension to indicate episode of care
 S30.810A
JAM
7th Character
Certain ICD-10-CM categories have 7th digit characters
 Applicable 7th character is required within the category
 If code requires 7th character and is not 6 characters, a
placeholder “X” must be used to fill empty character
 Ex: S05 Injury of eye and orbit, subsequent visit

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S05.00
 Looking
it up you find “x7th” meaning no 6th character exists but
there is a 7th character mandatory
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S05.00xD
JAM
Laterality
For bilateral sites, final character of code indicates
laterality
 Unspecified side codes if side not identified in medical
record
 If no bilateral code provided and condition is bilateral
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Assign separate codes for both left and right
Ex:
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H43.811 Vitreous degeneration, right side
H43.812 Vitreous degeneration, left side
H43.813 Vitreous degeneration, bilateral
H43.819 Vitreous degeneration, unspecified
JAM
Abbreviations
NEC “not elsewhere classifiable”
 NOS “not otherwise specified”
 “and” represents and / or
 “code also” instructs two codes may be required
 [ ] Brackets identify manifestation codes
 ( ) parenthesis terms are non essential modifiers
 : Colon incomplete term needing more modifiers
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JAM
Excludes Codes
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Excludes 1 – pure excludes notes
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Means “NOT CODED HERE”
Indicated code exclude should never be used same time as
code above it
 Ex
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congenital vs acquired condition
Exclude 2
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“Not included here”
Condition excluded is not part of the condition represented by
the code
JAM
Etiology / Manifestation Convention
Some conditions have underlying etiology and multiple
body system manifestations due to the etiology
 Coding convention requires underlying condition be
sequenced first, followed by manifestation
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“use additional code” note exists at etiology codes
“code first” note at the manifestation code
Ex; Dementia in Parkinson’s disease
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Code G20 represents etiology
[F02.80 or F02.81] represents manifestation of dementia
 With
behavioral or without behavioral disturbances
JAM
General Coding Guidelines

Locating a code in ICD-10-CM
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Locate term in Alphabetic Index
Then verify code in the Tabular List
Read and be guided by instructional notations appearing in
both
Essential to use BOTH
 Alphabetic
index doesn’t always provide FULL code
 Need Tabular List to assign laterality and 7th character
JAM
Sign & Symptoms
Codes that describe symptoms and signs, as opposed to
diagnosis
 Are accepted when a definitive diagnosis has not been
established
 Chapter 18
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JAM
Acute & Chronic Conditions
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Acute & Chronic
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Code acute or chronic
If condition is both, code both with acute first
Late Effects (Sequela)
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Residual effect after acute phase of illness or injury has
terminated
No time limit
Coding requires 2 codes sequenced in order
 Condition
first
 Late effect code second
JAM
External Cause Codes
Chapter 20
 Use full range of external cause codes to completely
describe:
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the cause,
the intent,
the place of occurrence,
and if applicable the activity of the patient at the time of the
event and
the patient’s status for all injuries and other health conditions
due to an external cause
JAM
Z Codes
Z codes are analogous to the ICD-9CM “V” codes
 Most rules of V codes transfer over to the use of Z codes
 Used to describe routine examinations of many varieties
 Each with different codes
 Ex Z00 Encounter for general examination without
complaint, suspected or reported diagnosis
 Ex Z01 Encounter for other special examination without
complaint, suspected or reported diagnosis

JAM
Steroid Responder Visit Scenario – Old Way
57 YOM with BRVO, s/p focal laser, IVDex, elevated
IOP, OS
 CPT 99214
 ICD: 365.04

JAM
Steroid Responder Visit Scenario – New Way

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57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS
CPT 99204
ICD: T38.0x5
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T38.0x1 = accident
T38.0x2 = self harm
T38.0x3 = assault
T38.0x4 = undetermined
T38.0x5 = adverse effect
T38.0x6 = under-dosing
ICD: H40.62 Glaucoma secondary to drugs, left eye
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Note states “code first” T36-T50 to identify drug
JAM
Notable & Quotable
“…Jonathan Swift, where are you today? The Lilliputians
are tying down the healthcare giant with 140,000 threads
and calling it a “fundamental advance” MD Tucson AZ
 “…this has everything to do with the government forcing
more expense, inefficiency and reimbursement delays on
already dispirited practitioners…many of my burned out
colleagues will gladly follow me into early retirement if
this continues” MD Meadville, PA
 ‘…if this is a small taste of the increasing role of
government involvement in healthcare, it is a wonder that
any young person has any interest in a career in
medicine” SDC, Pittsburgh, PA
JAM

Notable & Quotable
“…this is government medicine causing the addition of
more ancillary office personnel, more intrusion into the
patient’s privacy, more paperwork hours for doctors and
one more nail in the coffin of private practice” MD
Newport OR
 “..every contact will require one of 140,000 codes in
order to submit a bill. How much time will medical
providers spend choosing the right one, how much will
that raise overall medical costs and why is it all worth it?
MD Portland OR
 “..doctors closing their practices in droves; is there a code
for that? MD Niceville FL
JAM

Notable & Quotable
“…is there an app for that??” OD Los Angeles, CA
 “..the Mayan Calendar says the world comes to an end
the October before this becomes effective , so don’t
worry about any of this..” OD Belize City, Belize

JAM
Thank you
Missouri Eye Associates
McGreal Educational
Institute
Excellence in Optometric Education