Welcome to
CODEquest 2008!
Congratulations
to all who have passed the
Ophthalmic Coding Specialist Exam
CODEquest – Financial Disclosure
Ms. Vicchrilli
does not have any financial interest or
relationships to disclose.
CODEquest Topics
In the following patient examples, we
will cover:
• E&M vs. Eye codes
• Consultations
• Special testing
CODEquest Topics
• Modifier application
• Minor procedures for each specialty
• Major surgical procedures for each
specialty; and
CODEquest Topics
• Answer the really tough questions.
CODEquest Topics
• Billing for the interim exam between
cataract surgeries
• Billing for an injection and an exam the
same day
• Billing for OCT and fundus
photography on the same day
CODEquest Topics
• Coding for new corneal procedures
CODEquest Topics
• There will also be staff meetings.
Agenda
1. What’s new in 2008
2. Ethics
3. EOMB errors
CODEquest Topics
• Tips from the most effective offices.
What’s New in 2008
• Medicare Part B deductible increases
to $135 compared to $131 in 2007.
2008 CPT Update
Initial Nursing Facility Care
Change of description
99304 Physicians typically spend 25 minutes
with the patient and/or family or caregiver
99305 35 minutes
99306 45 minutes
2008 CPT Update
Subsequent Nursing Facility Care
Change of description
99307 Physicians typically spend 10 minutes
with the patient and/or family or caregiver.
99308 15 minutes
99309 25 minutes
99310 35 minutes
2008 CPT Update
• CPT code 67038 Vitrectomy, mechanical,
pars plana approach; with epiretinal
membrane stripping
– will be deleted and replaced with three new
codes
2008 CPT Update
67041 Vitrectomy, mechanical, pars plana
approach; with removal of preretinal cellular
membrane (eg, macular pucker)
67041
CCI edits:
36000, 36410, 37202, 62318, 62319, 64415,
64416, 64417, 64450, 64470, 64475, 65800,
65805, 65810, 65815, 66830, 66840, 66852,
66920, 66930, 66940, 67005, 67010, 67015,
67025, 67027, 67028, 67036, 67101, 67105.
67107, 67110, 67112, 67120, 67121, 67141,
67145, 67500, 67515, 68200, 90760, 90765,
90772, 90774, 90775. Mutually exclusive 69990
67041
RVUs: 30.23 no site-of-service differential
Global period: 90 days
Assistant-at-surgery: yes
2008 CPT Update
67042 with removal of internal limiting
membrane of retina (eg, for repair of
macular hole, diabetic macular edema),
includes, if performed, intraocular
tamponade (ie, air, gas or silicone oil)
67042
CCI edits:
36000, 36410, 37202, 62318, 62319, 64415,
64416, 64417, 64450, 64470, 64475, 66830,
66840, 66852, 66920, 66930, 66940, 67025,
67036, 67108, 67110, 67112, 67500, 90760,
90765, 90772, 90774, 90775. Mutually Exclusive
69990
67042
RVUs: 34.62 no site-of-service differential
Global period: 90 days
Assistant-at-surgery: yes
2008 CPT Update
67043 with removal of subretinal
membrane (eg, choroidal
neovascularization), includes, if performed,
intraocular tamponade (ie, air, gas or silicone
oil) and laser photocoagulation
67043
CCI edits:
36000, 36410, 37202, 62318, 62319, 64415,
64416, 64417, 64450, 64470, 64475, 66830,
66840, 66852, 66920, 66930, 66940, 67025,
67036, 67107, 67108, 67110, 67112, 67113,
67500, 90760, 90765, 90772, 90774, 90775.
Mutually Exclusive 69990
67043
RVUs: 36.33
Global period: 90 days
Assistant-at-surgery: yes
2008 CPT Update
 67113 Repair complex retinal detachment (eg,
proliferative vitreoretinopathy, stage C-1 or
greater, diabetic traction retinal detachment,
retinopathy of prematurity, retinal tear of greater
than 90 degrees), with vitrectomy and membrane
peeling, may include air, gas, or silicone oil
tamponade, cryotherapy, endolaser
phtoocoagulation, drainage of subretinal fluid,
scleral buckling, and/or removal of lens
67113
CCI edits:
G0186, 36000, 36410, 37202, 62318, 62319,
64400, 64402, 64405, 64415, 64416, 64417,
64450, 64470, 64475, 66830, 66840, 66850,
66852, 66920, 66930, 66940, 66982, 66983,
66984, 66985, 66986, 67005, 67010, 67015,
67025, 67028, 67030, 67031, 67036, 67039,
67040, 67041, 67042, 67101, 67105, 67107,
67108, 67110, 67112, 67141, 67145, 67208,
67210, 67218, 67220, 67221, 67227, 67228,
67500, 67515, 68200, 90760, 90765, 90772,
90774, 90775. Mutually Exclusive 69990
67113
RVUs: 39.88
Global period: 90 day
Assistant-at-surgery: yes
2008 CPT Update
 67229 Treatment of extensive or progressive
retinopathy, one or more sessions; preterm infant
(less than 37 weeks gestation at birth), performed
from birth up to 1 year of age (eg, retinopathyof
prematurity), photocoagulation or cryotherapy
67229
CCI edits:
36000, 36410, 37202, 62318, 62319, 64415,
64416, 64417, 64450, 64470, 64475, 67500,
67515, 90760, 90765, 90772, 90774, 90775.
Mutually Exclusive 69990
67229
RVUs: 26.23
Global period: 90 day
Assistant-at-surgery: no
CPT Update
Change of description - ?
67227 Destruction of extensive or progressive
retinopathy (eg, diabetic retinopathy), one or more
sessions, cryotherapy, diathermy
Old language
67227 Destruction of extensive or progressive
retinopathy (eg, diabetic retinopathy), one or more
sessions; cryotherapy, diathermy
CPT Update
Change of description
67228 Treatment of extensive or progressive
retinopathy, one or more sessions; (eg, diabetic
retinopathy), photocoagulation
Old language
Destruction of extensive or progressive
retinopathy (eg, diabetic retinopathy), one or more
sessions; photocoagulation (laser or xenon arc)
CPT Update
• 68816 Probing of nasolacrimal duct, with or
without irrigation; with transluminal balloon
catheter dilation
68816
CCI edits:
36000, 36410, 67202, 62318, 62319, 64415,
64416, 64417, 64450, 64470, 64475, 67500,
68810, 68811, 90760, 90765, 90772, 90774,
90775. Mutually Exclusive 69990
68816
RVUs: 15.91/5.67
Global period: 10 day
Assistant-at-surgery: no
CPT Update
Change of description
92135 Scanning computerized ophthalmic
diagnostic imaging, posterior segment, (eg,
scanning laser) with interpretation and report,
unilateral
CPT Update
Category III code:
0187T Scanning computerized ophthalmic
diagnostic imaging, anterior segment, with
interpretation and report, unilateral
 No RVUs – until a local policy developed, patient
is responsible for payment
New PhotoScreening Code
• 99174
Ocular photoscreening with
interpretation and report, bilateral
– (Do not report 99174 in conjunction with
92002-92014, 99172, 99173)
• Deleted 0065T to create new Category 1
code for photoscreening
• Not valued by the RUC
HCPCS Update
• Lucentis received
a
HCPCS
code
November 5th • J2778, ranibizumab injection 0.1mg effective
January 1, 2008. Put 5 in the unit field
ASC Update
• Effective January 1, 2008 all surgical procedures
will be ASC approved, with the exception of
- codes that contain the description of “with
hospitalization”
- procedures that require an over-night hospital
stay
Office of the Inspector General
• To promote integrity, economy, efficiency and
effectiveness within all HHS programs
• Chief audit and law enforcement executive for the
entire Department, including the Centers for
Medicare & Medicaid Services.
2008 OIG Work Plan
• Place of Service Errors
– Because different settings pay at different rates OIG
wants to ensure accurate reporting of setting
• E&M Services During Global Surgery Periods
– Investigation as to the number of E&M services
provided by physicians and reimbursed as part of the
global surgery fee
2008 OIG Work Plan
• Medicare Payments for Selected Physician
Services
– Very few details except that they will review
appropriateness of billing for physician services
• Medicare “incident-to” Services
– Will review medical necessity, quality of care and
documentation for these services
2008 OIG Work Plan
• Assignment Rules by Medicare Providers
– Providers can’t balance bill beneficiaries for amounts
in excess of the Medicare allowable
• Geographic Areas with High Utilization of
Ultrasound Services
– Examine disproportionately high Medicare allowed
charges and services per beneficiary
-codes affecting ophthalmology are:
– 76510, 76511, 76512, 76513, 76514, 76516, 76519,
76529
Questions?
CIGNA LCDs
Blepharoplasty
December 2005
Botulinum Toxin
January 2007
Cataract Extraction
Preoperative Evaluation
Computer Corneal
Topography
Extended Ophthalmoscopy
Fundus Photography
November 2004
November 2006
July 2007
November 2007
CIGNA LCDs
General Ophthalmological
September 2007
Services
Removal Benign Skin Lesion November 2007
SLGT
November 2007
Visual Field
YAG
November 2007
May 2007
• When you accept payment from a
third party payer, each will have its
own policies to follow:
- Medicare
- Non-Medicare or commercial payers
- Medicaid
E&M vs. Eye Codes
- Review requirements for E&M
- Review requirements for Eye codes
E&M vs. Eye Codes
99201
1.03
99202
1.77
99203
2.54
99204
3.91
99205
4.94
92002
92004
1.83
3.43
99241
1.35
99242
2.52
99243
3.46
99244
5.11
99245
6.24
E&M vs. Eye codes
99211
0.5
99212
1.03
99213
1.71
99214
2.57
99215
3.46
92012
1.93
92014
2.82
• The first several patients of the day
are established patients
Patient #1
• Patient c/o bumps
RUL, causing
significant
swelling x 2 days.
Slight discharge
in am. Blurred
vision. Warm
compresses some
help
Chief
complaint
Bumps
Location
Quality
Duration
Right upper
lid
Significant
2 days
Associated
signs
Blurred
vision
Modifying
factors
Warm
compresses
help
Patient #1
• Diagnosis chalazion (plural = chalazia)
373.2
• Excision is performed
Patient #1 – Coding Options
67800
Excision chalazion; single Put 2 in the unit
field
67800
Excision chalazion; single Append modifier
59 indicting two
separate sites
Excision chalazion;
E3 or no modifier
multiple, same lid
67801
Patient #1
99212
Established patient
level 2
-25
67801
Excision of chalazion; No modifier
multiple, same lid
$38
$146
Patient #1
• Note: Some non-Medicare payers
always bundled the exam with a minor
procedure performed on the same day.
Patient #2
• CC: FB sensation
OS x early this
am. +3 pain,
photophobia. Pt
building tool shed
Chief
complaint
Foreign body
Location
Left eye
Quality
Duration
+4 pain
Early
morning
Photophobia
Associated
signs
Modifying
factors
Working with
wood/metal
Patient #2
• Diagnosis 930.8 Foreign body
• Removal is performed
Patient #2
99213
92012
65222
Established patient
level 3; or
Intermediate exam
-25
$62
-25
$64
Removal of foreign
-LT
body, external eye;
corneal, with slit lamp
$69
Patient #3
• P/O cataract OS x three weeks
C/O decreased vision
DX Cystoid macular edema
Patient #3
• Is this a billable exam?
• If referred to a retina specialist – is it a
billable exam?
- within the practice?
- outside the practice?
Patient #4
• P/O cataract OD 1 month. Vision not
as good as it was previously. Presents
today for glaucoma check OS
• Exam revealed capsular haze OD, IOP
check OS, YAG performed OD
Patient #4
• Is this a billable visit?
• Is documentation sufficient?
• What modifiers should be appended?
Patient #4
• Exam modifiers 24 and 57
• YAG modifier RT
Patient #5
• CC: Progressive
decreased vision
OU x 3 months.
OD worse.
Difficulty
performing any
near work,
sewing, reading
Chief
complaint
Decreased
vision
Location
Both eyes
Quality
Duration
Progressive
Three months
Associated
signs
Right eye
worse
Modifying
factors
Problems
seeing at near
Patient #5
• Exam reveals bilateral cataracts.
IOLMaster is ordered
• Surgery scheduled for the right eye
• Patient requests P-C IOL. NEMB is
signed and specialized informed
consent given
Patient #5
99204
92004
92015
New patient,
level 4; or
-57 if surgery is
$144
performed within 3
days
Comprehensive -57 if surgery is
$126
exam
performed within 3
days
Refraction
N/A
Determined
by
physician
Patient #5
92136
92136
IOL Master payment -RT
= the global technical
component and the
professional
component of the right
eye; or
-TC -RT
-26 -RT
$86
$28
$58
Patient #5
V2788
-RT
Determined
Presbyopia-correcting
function of an intraocular -GY?? by
physician
lens for the amount the
patient pays out-ofpocket
Patient #6
• Exam reveals bilateral cataracts.
IOLMaster is ordered
• Surgery scheduled for the right eye
• Patient qualifies for toric IOL
Patient #6
A9270
Non-covered item or
service, for the amount
the patient pays out-ofpocket
-RT
Determined
by
-GY?? physician
Patient #5 and #6
• What if these patients need a YAG
capsulotomy within the global period?
• What if the patients request an IOL
exchange?
• Can we charge the patient out-ofpocket for these services?
Patient #5 and #6
66821
Laser surgery -78
(eg, YAG
laser) (one or
more sessions)
-RT $282
Payment will be 80%
of the allowable.
Don’t start a new
global period
66986
Exchange of
intraocular
lens
-78
-RT $808
Payment will be 80%
of the allowable.
Don’t start a new
global period
Patient #7
• This cataract patient is requesting
monovision (one eye distance, one eye
near) following cataract surgery.
• Are there additional fees a physician
can charge in this situation?
Patient #8
• The patient is so pleased with the
outcome of the right eye cataract
surgery, that within the global period,
surgery on the left eye is scheduled.
• A brief exam is performed. Is this a
billable exam?
Questions?
Ethics
Stated here are the Principles and Rules of
the Code Ethics that may come into play
when assigning CPT codes for care provided
to a patient.
Ethics - Background
The Principles of Ethics are aspirational and
inspirational guidelines, and are not enforceable by the
Academy’s Ethics Committee.
The Rules of Ethics, on the other hand, are mandatory
and prescriptive standards of minimally acceptable
conduct and are enforceable by the Academy’s Ethics
Committee.
A determination of failure to observe the Code of
Ethics will result in the Academy imposing appropriate
sanctions.
Principles of Ethics – Principle 5
• Fees for Ophthalmological Services.
Fees for ophthalmological services
must not exploit patients or others who
pay for the services.
Example – Principle 5
• A patient with AMD is seen for a routine
exam. The patient has recently gotten a new
job and now has a new health insurance
provider. This provider is one which the
physician knows is a prompt payer that
seldom challenges claims.
Example – Principle 5
• The physician orders a fluorescein
angiography even though there is no
documented change in the patient’s visual
fields.
• He states that the reason for the FA is to
document the baseline for the new insurance
company. He continues to order frequent
FAs on a stable patient.
Rules of Ethics – Rule 3
• Clinical Trials and Investigative Procedures.
Use of clinical trials or investigative procedures
shall be approved by adequate review
mechanisms. Clinical trials and investigative
procedures are those conducted to develop
adequate information on which to base prognostic
or therapeutic decisions or to determine etiology or
pathogenesis, in circumstances in which
insufficient information exists.
Rules of Ethics – Rule 3
• Clinical Trials and Investigative
Procedures.
Appropriate informed consent for these
procedures must recognize their special
nature and ramifications.
Rules of Ethics – Rule 3
• Dr. Z is a researcher in a clinical trial for an
investigational corneal trephine. Patients
enrolled in the clinical trial are provided care
free-of-charge as part of the parameters of the
funded trial.
• Patient A volunteered for the clinical trial
hoping to benefit from the new device; she has
corneal dystrophy as well as diminished vision
from nuclear-sclerotic cataracts.
Rules of Ethics – Rule 3
• Dr. Z orders a series of tests performed on
Patient A relating to her cataract rather than her
corneal dystrophy.
• Dr. Z knows these tests will be reimbursed even
though Patient A is involved in the clinical trial
solely for treatment with the investigational
trephine.
Rules of Ethics – Rule 3
• A doctor is testing a new IOL undergoing final clinical
trials. He informs the patient that he will perform
“routine cataract surgery” and expects that the patient
will be delighted with the outcome.
• The special nature of the IOL used is not revealed. The
surgeon then submits a claim to Medicare for 66984,
for which he will be reimbursed more than the
manufacturer would pay for the surgery in the clinical
trial.
Rules of Ethics – Rule 6
• Pretreatment Assessment.
Treatment shall be recommended only after a
careful consideration of the patient's physical,
social, emotional and occupational needs.
The ophthalmologist must evaluate the patient
and assure that the evaluation accurately
documents the ophthalmic findings and the
indications for treatment.
Rules of Ethics – Rule 6
• Pretreatment Assessment.
Recommendation of unnecessary treatment
or withholding of necessary treatment is
unethical.
Rules of Ethics – Rule 6
• Dr. X performs cataract surgery on a patient
with a pupil that dilates sufficiently to
perform cataract surgery, but not as well as a
routine case.
• Dr. X uses iris retractors as a “precaution”
and codes the higher-paying cataract surgery
code, 66982.
Rules of Ethics – Rule 7
• Delegation of Services.
Delegation is the use of auxiliary health care
personnel to provide eye care services for
which the ophthalmologist is responsible.
An ophthalmologist must not delegate to an
auxiliary those aspects of eye care within the
unique competence of the ophthalmologist
(which do not include those permitted by law to
be performed by auxiliaries).
Rules of Ethics – Rule 7
When other aspects of eye care for which the
ophthalmologist is responsible are delegated to
an auxiliary, the auxiliary must be qualified and
adequately supervised.
An ophthalmologist may make different
arrangements for the delegation of eye care in
special circumstances, so long as the patient's
welfare and rights are the primary
considerations.
Rules of Ethics – Rule 7
Dr. R performs a routine cataract surgery on Patient S,
an elderly man who is showing signs of senile
dementia.
Dr. R’s technician obtains a signature on the consent
form. An uneventful cataract surgery is performed.
On the first postop day, Patient S is seen by an
optometrist who routinely sees Dr. R’s postop patients.
Optometrist Q notes in the patient’s chart that she is
unable to visualize the fundus due to “blood in the
globe.”
Rules of Ethics – Rule 7
On postop day three, Patient S complains that his
vision is distorted and the eye is painful. OptometristQ, again notes the presence of considerable blood
obscuring adequate examination.
The patient is put on analgesics and asked to return in
two days. On postop day five, the patient complains of
no vision and a very painful eye; Optometrist Q refers
him to a retina specialist who diagnoses a total retinal
detachment.
Rules of Ethics – Rule 7
Reattachment surgery is performed to no avail; all
useful vision is lost.
Dr. R, the cataract surgeon, discovers this outcome and
begins to “back code”, indicating that he performed all
the postop care to avoid others learning that he
delegated this patient’s care to an optometrist who,
although licensed to perform the functions assigned to
her, was not apparently competent to do so, resulting in
the loss of the patient’s vision.
Rules of Ethics – Rule 8
• Postoperative Care.
The providing of postoperative eye care until the
patient has recovered is integral to patient
management.
The operating ophthalmologist should provide those
aspects of postoperative eye care within the unique
competence of the ophthalmologist (which do not
include those permitted by law to be performed by
auxiliaries).
Rules of Ethics – Rule 8
Otherwise, the operating ophthalmologist
must make arrangements before surgery for
referral of the patient to another
ophthalmologist, with the patient's approval
and that of the other ophthalmologist.
Rules of Ethics – Rule 7
The operating ophthalmologist may make different
arrangements for the provision of those aspects of
postoperative eye care within the unique competence of
the ophthalmologist in special circumstances, such as
emergencies or when no ophthalmologist is available,
so long as the patient's welfare and rights are the
primary considerations.
Fees should reflect postoperative eye care
arrangements with advance disclosure to the patient.
Rules of Ethics – Rule 7
A cataract surgeon performs an uncomplicated
cataract surgery by referral from an optometrist.
In the preoperative consent discussion, there is no
discussion of postoperative care arrangements.
On the first postoperative day, the surgeon states
that the eye is “perfect” and that his job is done.
Rules of Ethics – Rule 7
He codes 66984 with modifier 54 for the
surgery and 99024 for the postop visit, and
asks his secretary to schedule a visit with the
referring optometrist in one week, whose
office is 3 blocks away.
Rules of Ethics – Rule 9
• Medical and Surgical Procedures.
An ophthalmologist must not misrepresent
the service that is performed or the charges
made for that service.
Rules of Ethics – Rule 9
• Dr T has performed a routine cataract
extraction on Patient U. It is now the first
day postop and Dr. T tells the patient that her
eye “looks good,” but there’s some “haze to
the capsule” so just to be on the “safe side,”
he is going to schedule a YAG laser
capsulotomy in 13 weeks to avoid “visual
loss.”
Rules of Ethics – Rule 9
The capsule opacity is inconsequential and
asymptomatic. Nevertheless, the patient is
made to understand that there is a serious but
remediable problem, and gives consent for
the procedure.
Dr. T performs the YAG capsulotomy the
day after the global period for the cataract
surgery has passed, and submits a claim for
the procedure.
Rules of Ethics – Rule 9
Dr. W performs an exam on Patient V who presents
with foreign body sensation of three days’ duration.
Dr. W sees an eyelash floating on the surface of her
cornea. Dr. W removes the eyelash and checks the
patient’s other eye for the same reason. Dr. W tells
Patient V that he did indeed find a foreign body
and removed it. He quickly shows her the surface
of a gauze pad on which the “foreign body” lies.
Rules of Ethics – Rule 9
The patient cannot see the foreign body, but trusts Dr. W and
now feels better.
Dr. W instructs his staff to code the visit:
99213-25
65222
Level 3 established patient
Removal of foreign body, external eye;
corneal, with slit lamp
$62
$69
Rules of Ethics – Rule 10
Procedures and Materials.
Ophthalmologists should order only those
laboratory procedures, optical devices or
pharmacological agents that are in the best
interest of the patient. Ordering unnecessary
procedures or materials or withholding necessary
procedures or materials is unethical.
Rules of Ethics – Rule 10
Dr. Y sees Patient X for routine visit and notices
development of a pigmented choroidal lesion. Dr. Y
does not order photography to document the size
and shape of the lesion because he has already
ordered X-number of that test this month and
ordering another test will cause his numbers to go
“over the top” and will result in less reimbursement
under his contract.
Rules of Ethics – Rule 10
Dr. Y documents the findings, but down-plays the
finding in the patient’s chart and notes, “Next visit,
check status of pigmented lesion.”
Questions?
Patient #9
• Patient complains of “lesions” left upper lid x 2
weeks. Increasing in size, itching, no discharge.
• Exam reveals two lesions – 0.2 cm in size
• Probably benign – sending to pathology to confirm
• ABN obtained from patient
Patient #9 – Correct coding
11440 Excision, other benign lesion, except skin
tag, eyelids, 0.5 cm or less
1. CPT code 11440-E1 and 11440-59-E1
2. CPT code 11440
3. CPT code 11440-E1 and 11440-51-E1
Patient #9 – Correct coding
In addition to the appropriate level of exam
appended by modifier 25
2. CPT code 11440. Code is payable per session, not
per eye, not per lesion.
Patient #10
Patient c/o “baggy upper lid skin” getting worse
over several past years
Exam performed, photographs and VF ordered and
reveal need for combined functional ptosis and
blepharoplasty procedures
• The medical necessity for each procedure was
individually documented
Patient #10
• Interpretation and report reads,
“The visual field defect is related to both ptosis
and dermatochalasis”
• Question: What is the weak-link in this
documentation?
Patient #10
• In addition to the appropriate level of exam,
coding should be
92285 External
ocular
photography
Inherently
bilateral
92082 VF
Inherently
bilateral
No
modifier
CCI bundle
with 15823
$
(same date)
No
modifier
N/A
$
Patient #10
• Surgical coding
67904 Repair of
blepharoptosis
(tarso) levator
resection or
advancement
-50; or
E1 and E3;
or
RT and
LT; and
GA
15823 Blepharoplasty Add -51 to
excessive skin above if
required
Not bundled
with 15823
$662
2nd at
50%
Not bundled
with 67904
$306
50%
reduction
Patient #11
• What if one eye is functional and one is cosmetic?
• Claim submission is not required for the cosmetic
eye.
• If patient insists, code 15822-Eye-GY
Blepharoplasty, upper eyelid
• V50.1 Other plastic surgery for unacceptable
cosmetic appearance
Patient #12
• Pt c/o dry eye x several months. +2 burning,
frequent blinking. Previously tried artificial tears
& ointment. Uses a humidifier – still no help.
• Schirmer test and exam reveal keratitis OU
• Physician will insert punctal plugs in two lower
puncta
Patient #12
• In addition to the appropriate level of exam,
coding should be
68761 Closure of
lacrimal
punctum; by
plug, each
-50; or RT No CCI $137
and LT; or edits
50%
E2 and E4
reduction for
second
procedure
Patient #12
• In 2002 Medicare bundled the supply of the plug
with the insertion
• Non-Medicare payers may pay separately for the
supply of the plug
HCPCS code A4262 for collagen
HCPCS code A4263 for silicone; or
CPT code 99070 for supply. May require invoice
Patient #12
• There is no CPT code for Schirmer test.
• It is not a countable element of an exam
• You can’t bill the patient with the unlisted
procedure code
Patient #13
• Following an exam on a glaucoma suspect
patient, the physician orders a VF and
optic nerve scan on both eyes
Patient #13
• In addition to the appropriate level of exam,
coding should be
1. Bill for the VF and OCT.
2. Bill for the optic nerve scan only the two codes are
bundled in CCI. Optic nerve scan is payable per
eye and VF are inherently bilateral.
3. Have the patient return for any testing as the
services are bundled with the exam.
Patient #13
• In addition to the appropriate level of exam,
coding should be
1. Bill for the VF and OCT.
CPT code 92083
$77
CPT code 92135-RT
$45
CPT code 92135-LT
$45 (no reduction)
Patient #13
• Many 92135 LCDs state:
- Once per year is appropriate to follow preglaucoma patients or those with “mild damage”
- Patients with “moderate damage” may be followed
with optic nerve or visual fields. One or two tests
a year may be appropriate.
Patient #14
• Patient is within the global period of an LPI. An
anterior segment B-scans confirms the diagnosis
of plateau iris syndrome.
• An iridoplasty is scheduled
Patient #14
76513 Anterior segment $98 RT
B-scan
66762 Iridoplasty by
$414 Modifier
photocoagulation
78-RT
(one or more
sessions)
No CCI
edit
No CCI
edit
Patient #15
• Surgical patient requires an injection of 5FU in the
left eye postoperatively
• The injection, with the appropriate modifier, is
payable as is the drug
• No office visit is charged
Patient #15
• The correct modifier appended to the injection
code is:
1. -58
2. -78
3. -79
Patient #15
68200 Subconjunctival
injection
J9190 Fluorouracil
$39
-58 -LT
$
N/A
No CCI
edit
No CCI
edit
Patient #16
• Patient requires a scleral patch graft in
conjunction with placing a drainage
implant – left eye
Patient #16
992XX Appropriate
or
level of exam
9201X
66180 Aqueous shunt
to extraocular
reservoir
90-day global
$TBD -57
No CCI
edit
$1,007 -LT
No CCI
edit
67255
$ 374 -51 –LT
(50%)
No CCI
edit
Scleral
reinforcement
90-day global
Patient #17
• Patient within a global surgical period
requires removal of sutures. Laser
suture lysis is performed.
Patient #17
• Suture removal by laser or other means
is never payable in the postoperative
period
• Outside the global period, or if you are
not the surgeon, it is part of the exam
code billed
Patient #17
• It is inappropriate to bill for:
- CPT code 65222 Corneal FB; or
- CPT code 66250 Revision, repair of
operative wound
Patient #18
• C/O “bump” both
eyes, nasally on
the white of the
eye. Eyes are red
and irritated.
Chief
complaint
bump
Location
Both eyes
Quality
Duration
Irritated
Associated
signs
Red
Patient #18
• Diagnosis pinguecula
- CPT code 68110 Excision of
lesion, conjunctiva; up to 1cm
($221); or
- CPT code 68115 over 1 cm ($312)
Patient #19
• Diagnosis pterygium
- CPT code 65420 Excision or
transposition of pterygium;
without graft ($493) or
- CPT code 65426 ($606) with graft
Patient #19
• Use 65426 regardless of the
source of the graft
• CCI bundle with amniotic tissue
transfer
Patient #20
• Patient with progressive
pterygium that needs excision.
• Surgeon decides to perform at the
same surgical encounter as
cataract surgery in the same eye.
Patient #20
66984
65426
Cataract
extraction with
IOL
$664
Pterygium
excision with
graft
$606
Eye
Not
modifier bundled
with
65426
-51 –eye Bundled
modifier with
66984
Patient #21
• Patient with progressive
pterygium (left eye) that needs
excision.
• Surgeon decides to perform at the
same surgical encounter as
cataract surgery (right eye)
Patient #21
66984
65426
Cataract
-RT
extraction with
IOL (90-day)
$664
Pterygium
excision with
graft (90-day)
$303
(50%
reduction)
-59 -LT
Not
bundled
with
65426
Bundled
with
66984
Patient #22
• Patient requires cataract
extraction plus IOL and corneal
transplant
Patient #22
CPT code 65730 RT or LT
$1,560
CPT code 66984 51 and RT or LT $ 332
$1,892
Or
CPT code 66984 RT or LT
$ 665
CPT code 65730 51 and RT or LT $ 780
$1,445
Patient #23
Patient requires corneal transplant and IOL
exchange
Patient #23
CPT code 65755 RT or LT
$1,066
CPT code 66986 51 and RT or LT $ 404
$1,470
Or
CPT code 66986 RT or LT
$808
CPT code 65755 51 and RT or LT $533
$1,341
Patient #24
Keratoplasty is the general term for several variants of
corneal transplant. CPT code 65710 covers lamellar
keratoplasty in which only the outermost layers of cornea
are transplanted. CPT codes 65730, 65750, and 65755
refer respectively to full-thickness (penetrating) corneal
transplant in an aphakic patient, an aphakic patient (with
no native lens), and a pseudophakic patient (with an
artificial lens). The physician work allowance (WRVU)
for each of the three penetrating keratoplasty codes is
similar.
Patient #24
A relatively newer procedure is term “Descemet’s
stripping endothelial keratoplasty (DSEK)” or
“deep lamellar endothelial keratoplasty.” This
procedure involves a small incision to allow
intraocular placement of endothelium harvested
from a donor cornea after the stripping off of
diseased corneal endothelium.
Patient #24
Microkeratome-based (automated) preparation
of the donor endothelium may be used. This
technique offers certain clinical advantages while
achieving the goal of penetrating keratoplasty in
patients with disease largely related to endothelial
dysfunction.
Patient #24
Until such time that a more specific code is
released, many payers are allowing the new
Descemet’s stripping procedure coded as
65730, 65750, 65755, or 66999 (based on the
patient’s lens status).
– Offices MUST confirm with the specific
payer that this coding is correct.
Patient #24
Coding with unlisted procedure code 66999 is
not incorrect but will trigger delays for
additional documentation requests, processing,
review, and cross-walking of reimbursement,
and resultant potential access to care concerns.
Trailblazer states require 66999 for coverage.
Questions?
Explanation of Benefits
• When processing EOMBs consider:
- How well trained is the staff person?
- See addendum
- Explanation of Medical Benefits, Unlock Its
Secrets
Patient #25
• Patient has bilateral lateral rectus resections
(both eyes previously underwent strabismus
surgery).
• Surgeon also explores the inferior obliques.
Patient #25
67311
Strabismus
surgery, recession
or resection
procedure; one
horizontal muscle
+67331 Strabismus surgery
on patient with
previous eye
surgery
+67340 Strabismus surgery
involving
exploration/and or
repair
-50 or RT and LT
$516
-50 or RT and LT
$260
Medicare only allows
payment for one eye
-50 or RT and LT
Medicare only allows
payment for one eye
$306
Patient #26
• In addition to the primary strabismus surgery,
the physician performed an adjustable suture.
• But instead of adjusting the suture in the ASC
recovery room following surgery, the
adjustment was performed in the office the
next day.
Patient #26
Can CPT code +67335 Placement of
adjustable suture(s) during strabismus
surgery, including postoperative adjustment(s)
of suture(s) be billed when performed the next
day in the office? ($134)
Patient #27
• Physician orders fundus photography (92250)
and OCT (92135) performed on the same day.
• The codes are bundled in CCI.
• Is it ever appropriate to unbundle?
Patient #28
• Physician orders optic nerve scan for a
glaucoma and a retinal diagnosis?
• Is it ever appropriate to bill 92135 per eye for
each diagnosis?
Patient #29
• Physician performed an exam, OCT and an
injection of Macugen, Avastin, or Lucentis on
a patient in a skilled nursing home.
• Are there billing issues?
Patient #29
CPT code
Description
9921X-25
or
Appropriate Exam
level of exam
9201X-25
92135
OCT
92135-26-RT 92135-TC-RT
92135-26-LT 92135-TC-LT
Injection
Injection
67028-eye
Unilateral
payment
67028
HCPCS
code
Part B billing SNF billing
Drug
Patient #29
• Skilled nursing facility bill affects coverage
for:
- the technical (TC) component of special testing
services
- post-cataract glasses
- injected drugs
- NTIOLs
Patient #30 – Retinal cases
• Tip: Look at the diagnosis, the reason for
surgery. The base vitrectomy code will either
be a “repair of retinal detachment (RD) code”
or a “vitrectomy” code.
Patient #30 – Retinal cases
Vitrectomy with Epiretinal Membrane Stripping
•
Until December 31, 2007 CPT code 67038-eye modifier
•
After January 1, 2008
CPT code 67041-eye modifier
Patient #31 – Retinal cases
Scleral Buckle, Vitrectomy and Epiretinal Membrane
Stripping
•
Until December 31, 2007
CPT code 67038-eye modifier
CPT code 67108-51-eye modifier
•
After January 1, 2008
CPT code 67113-eye modifier
Patient #32 – Retinal cases
Macular Hole
Until December 31, 2007
CPT code 67038-eye modifier
After January 1, 2008
CPT code 67042-eye modifier
Patient #33 – Retinal cases
Macular Hole with Retinal Tear
•
The surgeon finds a retinal tear during surgery to repair a
macular hole. The tear is treated by endolaser.
Until December 31, 2007
CPT code 67038-eye modifier
CPT code 67039-eye modifier
After January 1, 2008
CPT code 67042-eye modifier
Patient #34 – Retinal cases
Complex Diabetic Traction Retinal Detachments
Until December 31, 2007
CPT code 67108-eye modifier
CPT code 67038-51-eye modifier
After January 1, 2008
CPT code 67113-eye modifier
Patient #35 – Retinal cases
Vitrectomy and Panretinal Photocoagulation for
Diabetes
For a straight forward vitreous hemorrhage treated with a
vitrectomy and endophotocoagulation
CPT code 67040-eye modifier
Patient #35 – Retinal cases
Vitrectomy and Panretinal Photocoagulation for
Diabetes
When extensive membrane stripping is done for the
proliferative disease and endolaser panretinal
photocoagulation
Until December 31, 2007
CPT code 67038-eye modifier
CPT code 67040-51-eye modifier
After January 1, 2008 67040-eye modifier
Lens complications
The following procedures are bundled
with 67036 Vitrectomy, mechanical,
pars plana approach; in the CCI.
66820
66830
66840
66920
66930
66940
Discission of secondary membranous cataract
Removal of secondary membranous cataract
Removal of lens material; aspiration technique
intracapsular
intracapsular, for dislocated lens
extracapsular
Lens complications
The next set of three codes were bundled with
67036 Vitrectomy, mechanical, pars plana
approach. Unbundled January 2005. Modifier
59 no longer needed.
66982
66983
66984
Complex cataract
Intracapsular cataract with IOL
Cataract extraction with IOL
Lens complications
The next set of two codes were unbundled with
67036 Vitrectomy, mechanical, pars plana
approach. Unbundled April 2003. Modifier 59
no longer needed.
66985
66986
Secondary IOL
IOL exchange
Lens complications
•If vitrectomy is performed only to
accomplish the cataract surgery then it
is integral to the cataract surgery and
not separately payable.
Consultations – clarification language
•Clarification
A transfer of care occurs when a physician or
qualified NPP requests that another physician or
qualified NPP take over the responsibility for
managing the patients’ complete care for the
condition and does not expect to continue treating or
caring for the patient for that condition.
Tips from the most effective offices
Tips from the most effective offices
Medicare fee schedule
obtained/implemented by January 1st of
each year
Non-Medicare fee schedules
obtained/implemented after July 1st of each
year
Tips from the most effective offices
Quarterly run a procedure productivity
report for each physician in the practice
Identify these high-volume utilization
codes
Tips from the most effective offices
Conduct an internal chart audit of two or
three of the charts from that particular code
for that period of time
This is the way all payers conduct their
audits
Tips from the most effective offices
Develop a protocol for processing requests
for records from any source
- Type any notes that aren’t legible
Tips from the most effective offices
Sign-up for payer list serves. Develop a
protocol for disseminating pertinent
information
Tips from the most effective offices
Review current LCDs. These are the rules
and regulations by which you will be held
accountable in an audit
Tips from the most effective offices
Review CCI impact on your coding each
quarter
- Coding Bulletin
- Coding Coach
- http://www.aao.org/aaoesite/coding/
Tips from the most effective offices
Develop a protocol for working denials –
within 72 hours of EOMB receipt
Develop a protocol for processing refunds
– insurance and patient
Tips from the most effective offices
Collect all copays, balances owed,
refraction charges, etc, at the time of
service
Tips from the most effective offices
Stay current with coding issues
- Washington Report
- EyeNet’s Savvy Coder
- AAOE’s Coding Bulletin
- AAOE’s etalk, eexpert, eretina
Tips from the most effective offices
Have documentation/coding as a topic at
each staff meeting
Physician Quality
Reporting Initiative
2008 Update
PQRI 2008
• Two components:
- updates for 2008
- implementation guide for those who have not
participated previously
PQRI 2008
• There will not be a question and answer period for
the call.
• Questions may be submitted to PQRI@aao.org
- Questions received will be added to the Q&A
section of www.aao.org/pqri
PQRI 2008
• CMS will again provide up to a 1.5 percent bonus
for physicians who voluntarily report on quality
measures during 2008, drawing on the $1.35
billion Physician Assistance and Quality Initiative
Fund. PQRI reporting begins January 1, 2008
through December 31, 2008.
PQRI 2008
• Ophthalmologists are welcome to use any
measures that apply to their patient base
• Complete details of all 134 measures can be found
at
http://www.cms.hhs.gov/PQRI/Downloads/2008P
QRIMeasureSpecs.pdf
PQRI 2008 – Deleted measures
• Measure 13 Age-Related Macular Degeneration:
Age-Related Eye Disease Study (AREDS)
Prescribed/Recommended;
• Measure 15 Cataracts: Assessment of Visual
Function Status;
• Measure 16 Cataracts: Documentation of PreSurgical Axial Length, Corneal Power
Measurement and Method IOL Power Calculation;
and
• Measure 17 Cataracts: Pre-Surgical Dilated
Fundus Evaluation
PQRI 2008 – Current measures
• Measure 12, Primary Open Angle Glaucoma:
Optic Nerve Evaluation
- addition of modifier 3P. Documentation of system
reason(s) for not performing an optic nerve head
evaluation
PQRI 2008 – Current measures
• Measure 14, Age-Related Macular Degeneration:
Dilated Macular Examination
- addition of modifier 3P. Documentation of
system reason(s) for not performing a dilated
macular examination
PQRI 2008 – Current measures
• Measure 18, Diabetic Retinopathy:
Documentation of Presence or Absence of Macular
Edema and Level of Severity of Retinopathy
- addition of modifier 3P. Documentation of
system reason(s) for not performing a dilated
macular or fundus examination
PQRI 2008 – Current measures
• Measure 19, Diabetic Retinopathy:
Communication with the Physician Managing
Ongoing Diabetes Care
This measure is now reported using CPT Category
II code and HCPCS G codes.
PQRI 2008 – Measure 19
• CPT Category II code 5010F findings of dilated
macular or fundus exam communicated to the
physician managing the diabetes care, and
• HCPCS G code G8397 Dilated macular or fundus
exam performed, including documentation of the
presence or absence of macular edema and level of
severity of retinopathy
PQRI 2008 – Measure 19
• What if the measure was not performed on a
qualifying patient?
PQRI 2008 – Measure 19
• 5010F
- 2P patient reason for not communicating with
PCP; or
- addition of modifier 3P system reason for not
communicating with PCP; or
- 8P findings not communicated, reason not
otherwise specified
and
PQRI 2008 – Measure 19
• G8398 dilated macular or fundus exam not
performed
- no modifier, just the HCPCS G code
PQRI 2008 – Measure 117
• Dilated Eye Exam in Diabetic Patient
• Definition: Percentage of patients aged 18 through
75 years with a diagnosis of diabetes mellitus who
had a dilated eye exam
PQRI 2008 – Measure 117
• Description
- This measure is to be reported a minimum of once
per reporting period for patients with diabetes
mellitus.
- This includes patients with diabetes who had one
of the following: A retinal or dilated eye exam by
an eye care professional (optometrist or
ophthalmologist) during the reporting period, or a
negative retinal exam (no evidence of retinopathy)
by an eye care professional in the year prior to the
reporting period.
PQRI 2008 – Measure 117
• Description
- For dilated eye exams performed 12 months prior
to the reporting period, an automated result must
be available.
PQRI 2008 – Measure 117
• CPT Category II Codes
-2022F Dilated retinal eye exam with interpretation by an
ophthalmologist or optometrist documented and reviewed;
or
- 2024F Seven standard field stereoscopic photos with
interpretation by an ophthalmologist or optometrist
documented and reviewed; or
- 2026F Eye imaging validated to match diagnosis from
seven standard field stereoscopic photos results
documented and reviewed; or
- 3072F Low risk for retinopathy (no evidence of
retinopathy in the prior year)
PQRI 2008 – Measure 117
• Code the Category II code in addition to the
appropriate level of Evaluation and Management
or Eye code exam: 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99217, 99218, 99219,
99220, 99241, 99242, 99243, 99244, 99245,
99455, 99456
PQRI 2008 – Measure 117
• Modifier Application
- 8P Dilated eye exam was not performed, reason
not otherwise specified
PQRI 2008 – Measure 124
• Health Information Technology (HIT) Adoption/Use of Health Information Technology
(Electronic Health Records)
PQRI 2008 – Measure 124
• Definition
- To qualify, the provider must have adopted a
qualified electronic medical record (EMR). For
the purpose of the measure, a qualified EMR can
either be a Certification Commission for
Healthcare Information Technology (CCHIT)
certified EMR or if not CCHIT certified, the
system must be capable of all of the following:
PQRI 2008 – Measure 124
• Generating a medication list
• Generating a problem list
• Entering laboratory tests as discrete searchable
data elements
• The measure is to be reported at each visit
occurring during the report period.
PQRI 2008 – Measure 124
• G Code (instead of Category II code)
- G8447 Patient encounter was documented using a
CCHIT certified EMR; or
- G8448 Patient encounter was documented using a
non-CCHIT certified EMR; or
- G8449 Patient encounter was not documented
using an EMR due to system reasons such as
system being inoperable at the time of the visit.
This implies that an EMR is in place and generally
available
PQRI 2008 – Measure 124
• CPT and HCPCS Codes
90801, 90802, 90804, 90805, 90806, 90807,
90808, 90809, 92002, 92004, 92012, 92014,
96150, 96151, 96152, 97001, 97002, 97003,
97004, 97750, 97802, 97803, 97804, 98940,
98941, 98942, 99201, 99202, 99203, 99204,
99205, 99211, 99212, 99213, 99214, 99215,
99241, 99242, 99243, 99244, 99245, D7140,
D7210, G0101, G0108, G0109, G0270, G0271
PQRI 2008 – Measure 124
• Diagnosis Codes
- No diagnosis codes are associated with this
measure
• Modifiers
- No modifiers are associated with this measure
PQRI 2008 – Measure 125
• Health Information Technology (HIT) –
Adoption/Use of e-Prescribing
PQRI 2008 – Measure 125
• Definition
• Qualifying providers have adopted an e-Prescribing
system for all patients age 18 years and older and the
extent of use in the ambulatory setting. To qualify this
system must be capable of all of the following:
• Generating a complete active medication list incorporating
electronic data received from applicable pharmacy drug
plan(s) if available
• Selecting medications, printing prescriptions,
electronically transmitting prescriptions, and conducting
all safety checks
- automated prompts that offer the provider information on
the drug being prescribed, potentially inappropriate dose
or route of administration of a drug, drug to drug
interactions, allergy concerns, or warnings and cautions
PQRI 2008 – Measure 125
• Providing information related to the availability of
lower cost, therapeutically appropriate alternatives
(if any)
• Providing information on formulary or tiered
formulary medications, patient eligibility, and
authorization requirements received electronically
from the patient’s drug plan
PQRI 2008 – Measure 125
• HCPCS G Codes
- G8443 All prescriptions created during the encounter were
generated using a qualified e-Prescribing system; or
- G8445 No prescriptions were generated during the
encounter; or
- G8446 Some or all prescriptions generated during the
encounter were handwritten or phoned in due to one of the
following: required by state law, patient request, or
qualified e-Prescribing system being temporarily
inoperable
PQRI 2008 – Measure 125
• CPT and HCPCS Codes
• 90801, 90802, 90804, 90805, 90806, 90807,
90808, 90809, 92002, 92004, 92012, 92014,
96150, 96151, 96152, 99201, 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245,
G0101, G0108, G0109
PQRI 2008 – Measure 125
• Diagnosis Codes
- No diagnosis codes are associated with this
measure
• Modifiers
- No modifiers are associated with this measure
PQRI 2008 – Implementation
 PQRI reporting is voluntary, not mandatory.
• The reporting time frame is January 1 to December
31, 2008.
PQRI 2008 – Implementation
• The bonus is contingent on
(a) achieving 80 percent success for patients that
have a disease/diagnosis that a quality measure
you selected is being reported (e.g., examining the
optic nerve for a glaucoma patient) and
(b) achieving that success rate for three quality
measures (or fewer measures if less apply).
PQRI 2008 – Implementation
• The bonus will be paid out as a lump sum in mid2009.
• The bonus will be applied to 100 percent of Part B
billings for the period except for drugs, other
biologics and durable medical equipment. There is
a cap, which ensures that a physician who only
reports a few cases doesn't get the same size bonus
as a physician who reports quality measures
frequently on his/her patients. Congress imposed a
cap based on a complex formula.
PQRI 2008 – Implementation
• There is no need to sign-up to participate. Just
begin to report the measures beginning January 1,
2008.
• You cannot report on patients seen in nursing
facilities or in Medicare Advantage programs.
• Report on Medicare, Railroad Medicare, and
Medicare as a secondary payer.
PQRI 2008 – Implementation
 No dollar amount is listed in the Medicare Fee
Schedule for the Category II or G codes, but the
charge box should not be left blank.
 If your system or the payer system won’t accept a
zero charge, post 0.01.
PQRI 2008 – Implementation
 Not everyone in the practice has to select the same
measures. Nor does everyone in the practice need
to participate.
 Since the individual reporting is based on the NPI,
only those patients treated by that physician will
count towards the 80 percent and the bonus
calculation. However the more participating
physicians in the practice, the greater the total
bonus.
PQRI 2008 – Implementation
• Begin by selecting the measure(s) applicable to you.
• Make sure your computer software will accept the
Category II and G codes as well as the P modifiers.
• Consider running a diagnosis code productivity report
from the list of denominators (diagnosis codes) for the
measure(s) you’ve selected. This will alert you as to
which additional diagnosis codes are available that you
might not be using already.
PQRI 2008 – Implementation
• PQRI Modifiers
- There will be situations when a modifier is appropriate in
addition to the Category II or G code to explain why a
measure could not be completed.
- 1P Documentation of medical reason(s) for not performing
a measure.
- 2P Patient declined for economic, social, or religious
reasons.
- 3P Performance measure exclusion modifier due to system
reasons. Insurance coverage/payer related limitations or
resources to perform the services not available.
- 8P Reasons not otherwise specified.
•PQRI for 2009?
PQRI 2009
• 5 new and 1 revised eye measures have been
approved by the AMA PCPI and AQA
• Not included by CMS in the final rule
– Academy working to seek implementation
Questions?
Door Prizes