Balancing Vision Plan Billing Versus Medical Billing Vision Plan Billing Ver… · Balancing the...

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Balancing the Vision Plan Benefit Versus Medical Insurance Billing 5/21/17 [email protected] 814-931-2030 cell 1 Balancing the Vision Plan Benefit Versus Medical Insurance Billing Greg Caldwell OD, FAAO Disclosures - Greg Caldwell, OD, FAAO $ Will mention many products, instruments and companies during our discussion ¬ I don t have any financial interest in any of these products, instruments or companies $ Pennsylvania Optometric Association President 2010 2 POA Board of Directors 2006 - 2011 $ American Optometric Association, Trustee 2013 - 2016 ¬ Thank you to the members and those who join $ I never used or will use my volunteer positions to further my lecturing career $ Lectured for: Shire, BioTissue, Optovue $ Advisory Board: Allergan $ Evolve Medical Director for PA Course Description o Most patients have both vision plan benefits and medical insurance coverage o Managing the benefits and coverage without compromising patient care can seem complicated o Effectively being able to do so will be beneficial to your practice and your patients o This course will offer several guidelines to help you with one of the most challenging billing issues in an optometric office Objectives $Review and discuss Vision Plan Benefits $Review and discuss Medical Insurance $Review and discuss payers of eye care $Discuss when you bill vision plans versus the medical insurance $Discuss the practice influences and quality outcomes when not performed properly Rules During this Presentation $There are no rules $Have fun, enjoy and relax $Ask questions at the time of the case Can anyone here tell me the only dumb question? A question that is not asked Disclaimer $This lecture uses CPT and Medicare/Medicaid guidelines ¬ Subject to change $This is not the only way to bill ¬ Ultimately it’s the individual physician’s decision $If fees are mentioned they are only examples and not fees you should be billing

Transcript of Balancing Vision Plan Billing Versus Medical Billing Vision Plan Billing Ver… · Balancing the...

Page 1: Balancing Vision Plan Billing Versus Medical Billing Vision Plan Billing Ver… · Balancing the Vision Plan Benefit Versus Medical Insurance Billing 5/21/17 Grubod@gmail.com 814-931-2030

BalancingtheVisionPlanBenefitVersusMedicalInsuranceBilling

5/21/17

[email protected] 1

Balancing the Vision Plan Benefit

VersusMedical Insurance Billing

Greg Caldwell OD, FAAO

Disclosures- Greg Caldwell, OD, FAAO

$ Will mention many products, instruments and companies during our discussion¬ I don’t have any financial interest in any of these products, instruments

or companies

$Pennsylvania Optometric Association –President 2010 2 POA Board of Directors 2006-2011

$American Optometric Association, Trustee 2013-2016¬ Thank you to the members and those who join

$ I never used or will use my volunteer positions to further my lecturing career

$Lectured for: Shire, BioTissue, Optovue$Advisory Board: Allergan

$Evolve Medical Director for PA

Course Description

o Most patients have both vision plan benefits and medical insurance coverageo Managing the benefits and coverage without compromising patient care can

seem complicatedo Effectively being able to do so will be beneficial to your practice and your

patientso This course will offer several guidelines to help you with one of the most

challenging billing issues in an optometric office

Objectives

$Review and discuss Vision Plan Benefits$Review and discuss Medical Insurance$Review and discuss payers of eye care$Discuss when you bill vision plans versus the medical insurance$Discuss the practice influences and quality outcomes when not performed

properly

Rules During this Presentation

$There are no rules$Have fun, enjoy and relax $Ask questions at the time of the case

Can anyone here tell me the only dumb question?

A question that is not asked

Disclaimer

$This lecture uses CPT and Medicare/Medicaid guidelines¬ Subject to change

$This is not the only way to bill¬ Ultimately it’s the individual physician’s decision

$If fees are mentioned they are only examples and not fees you should be billing

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Not A Billing Course

$Not determining if we should bill 92xxx or 99xxx

$A course on what to do when a patient has Vision Plan Benefits/Wellness Coverage and Medical Insurance

“Insurance”

$Insurance- a practice or arrangement by which a company or government agency provides a guarantee of compensation for specific loss, damage, illness, or death in return for payment of a premium

$Health insurance- is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured¬ Reimburse the insured for expenses incurred from illness or injury¬ Pay the care provider directly

Medical Insurance

Sheep

Vision Coverage

Goats

Vision Plan Benefitversus

Medical Insurance

$Medical Insurance$Vision Insurance $Vision Coverage$Vision Plan Benefits$Wellness Coverage ¬Pre-paid benefit

¬Discount plan

Eye Care

$Optometrist provide wellness eye care and medical eye care¬ They are independent examinations

¬ Unrelated to each other¬ At times include some of the same testing and procedures

2 However, different– Findings– Documentation

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“Third Party Payer”

$Patient$Doctor$Insurance or vision benefit plan

Who pays for the eye care?$Patient- The cash paying patient

¬ Wellness or comprehensive eye exam¬ Medical eye care

$Vision plan¬ Wellness or comprehensive eye exam

$Commercial medical Insurance¬ Private Health Insurance- paid for by someone other than government¬ Medicare Advantage plans

2 Administered by private insurance companies

$Federal Insurance/Programs¬ Medicare ¬ Medicaid¬ Others

2 Veterans benefits2 Children’s Health Insurance Plans (CHIP)

Patient

$Wellness or medical eye care¬Paid today

Vision Plan Benefit or Wellness

$Few rules$Not a medical complaint$Entryway to medical eye care$Refractive Codes

¬ Myopia¬ Astigmatism

¬ Presbyopia

Commercial Medical Insurance

$Rules apply for coverage$Don’t always require a medical complaint

¬ Only a medical problem

$Medical diagnosis to justify¬ Exam¬ Procedure/s

Federal Insurances- Medicare

$Lots of rules apply for coverage$Must have a medical complaint or symptom

¬ More coming, but blurred vision doesn’t always work

$Medical diagnosis to justify the medical complaint for exam and procedures$NEVER covers routine vision exam or refraction

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$Medicare recipients expect their Medicare to cover the cost of their care$Part B Medicare deductible of $183.00 for 2017 ($147.00 in 2015)

¬ To collect or not to collect – is it a question?

$Medicare pays 80% of allowed fee¬ Patient is responsible for the 20% (always)

$Traditional Medicare never, NEVER pays for refraction¬ Or any other wellness care

“Traditional” Medicare + Patient Medicare “Advantage” + Patient

$Generally the patient thinks they still have “traditional” Medicare coverage$Administered by a commercial payer

¬ Regional and payer differences2 Highmark, Capital, and Independence BCBS all offer Medicare Advantage Plans in PA

$Has to offer the same benefits as Medicare¬ Can offer more than Medicare

¬ Doesn’t have to pay the same

$Get the copay!¬ Why???

Medicaid and MCO’s

$Follows most rules that apply to Medicare$Medical billing doesn’t require a medical complaint

¬ Need a medical problem

$Pennsylvania¬ Patients get fee for service Medicaid for 90 days then pick a Managed Care Organization

(MCO)2 Gateway Health2 UPMC for You2 Health Partners Plans2 Keystone First

Medicaid and MCO’sHealthChoices Map of 2017

$Depending on the MCO¬Sometimes the Vision Plan pays

for medical and vision benefit¬Sometimes the medical benefit

pays for medical and vision plan pays vision benefit

CPT and ICD-10

$CPT- Current Procedure Terminology

$ ICD- 10 International Classification of Disease, Version 10

CPT- Current Procedure Terminology

$What procedure you do¬Exam, test, minor surgery ¬99000 Evaluation/Management

(E/M) codes2 99204/99214, new/established

¬92000 General Ophthalmological Services2 92004/92014, new/established

2 92310- CL evaluation

¬92000 Diagnostic testing2 92133- OCT Optic nerve and NFL2 92250- Fundus photography

¬60000 Surgical procedures2 68761- Punctal plug insertion

2 65222- Cornea FB removal with slit lamp

¬70000 Radiology testing2 76514- Pachymetry via ultrasound

¬80000 Laboratory testing2 83516- InflammaDry

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S-Code

$Introduced in 2004$S0620/S0621$First within the Healthcare Common Procedure Coding System (HCPCS) to

include refraction as part of a routine eye examination$The only trouble is that HCPCS provided no further detail in defining a

routine eye exam compared to a comprehensive eye exam¬ Insurers free to interpret

True or False

$An optometrist is not a medical doctor so he or she is not allowed to use ICD-10 codes for systemic diseases¬ Except for diabetes and hypertension since they can cause eye complications? ¬ For example:

2 Hepatitis2 Systemic lupus erythematous 2 Multiple sclerosis

$FALSE!

ICD- 10 International Classification of Disease, Version 10

$The diseases you found¬Myopia

2H52.11 myopia right eye2H52.12 myopia left eye2H52.13 myopia both eyes

¬H40.1131 glaucoma both eyes mild¬H04.123 Dry eye syndrome of bilateral lacrimal glands¬E11.9 Type 2 diabetes mellitus without complications

CPT and ICD-10 Must Match

$92133 OCT Optic nerve and NFL$H40.1131 POAG both eyes mild – match$H52.13 myopia both eyes – will be denied

$68761- Punctal plug insertion $H04.123 Dry eye both eyes- match$H40.1131 POAG both eyes mild – will need denied

$83516- InflammaDry$H04.123 Dry eye both eyes – match$H40.1131 POAG both eyes mild – will need denied

Vision Plan Benefit CPT and ICD-10

$CPT¬92000

2 92002/92004

2 92012/920142 92015

¬S-codes

$ICD-10¬H52.11¬H52.12¬H52.13¬H52.01¬H52.02¬H52.03¬H52.40

Before Seeing the Patient

$Find out patients vision plan benefits and medical coverage¬Specialist copay or coinsurance¬Procedure copay

2 If any

¬Deductible2 How much they have met

¬Vision plan 2 Exam eligible

2 Glasses or CL benefits

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Finding Out Why the Patient is “Really” There

¬Medical eye problem¬Medical condition that can affect

the eye2 Diabetes, thyroid, rheumatoid

arthritis, or another

¬Medical eye problem with refractive concerns

¬Comprehensive eye exam2 Not a routine eye exam

$This can happen:¬Making the appointment¬Check-in¬Pre-test¬History with technician¬With the doctor

$The sooner the better¬Doesn’t always happen that way

Myth versus Truth Billing Wellness or Medical Insurance

$Myth:¬ Is only based on why the patient is there

¬ Is determined by his/her insurance coverage

$Truth:¬ The entire exam determines how the patient is billed

Question?

$You always have to have medical symptoms to bill for medical services?

$False!

$You have to have a medical reason for the visit

What can qualify as a medical reason for the visit?

$Symptoms¬ Patient history

$Signs from the examination$Physician direction (the most powerful)$Request for evaluation of a condition from the patient or another health

provider

$My patient reports they have blurred vision – I have a medical reason for the visit and can start running tests!

WRONG!!!$Blurred vision is a medical reason for the visit ONLY if it caused by a medical

condition$Doubting Thomas? Contact Craig Thomas in Dallas and he’ll scan you a copy

of the $36K check he wrote to Medicare!

“Always Use Blurred Vision” as the Reason for the Visit

Medical Symptoms

$Almost anything¬ Not blurred vision all the time

2 Sometimes might work

$Never¬ Routine eye exam¬ Yearly check up

$These are good:¬ Watery eyes, eye hurts, burning eyes, fluctuating vision, growth on eyelid, difficulty with

night driving, glare, floaters, loss of vision…

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What to do When a Patient Presents for a “Routine Eye Exam” and Has a Medical Issue

$It happens all the time$Let’s discuss a patient with diabetes

¬Practice influences¬Quality outcome/measures¬HEDIS or Star Scores¬Primary Care Physician Influences

Discussion

$A patient with diabetes¬Primary care physician says you

need an eye exam¬What happens?¬Request for evaluation of a

condition from the patient or another health provider

Discussion

$A patient with IOPs of 26 mm Hg and family history of glaucoma¬Patient is asymptomatic ¬Found during the wellness exam¬Physician direction

2RTC for AM IOP ck, pachymetry, and OCT NFL-GCC

Discussion

$Can you billing Vision Benefit Plan and Medical Insurance the same day?¬Vision Benefit Plan and Medical Insurance for procedure?

2 I.E., photos, OCT

¬Medical Insurance for visit and Vision Benefit Plan for hardware/glasses?2 Glaucoma follow up and glasses

¬Vision Benefit Plan and E/M examination?2 Yes, rarely, know the rules

Discussion

• New 45 year old female patient presents stating she needs her contact lens Rx renewed• She wears Ciba Dailies periodically for social events. • Medical history includes arthritis and she has been on Plaquenil for two years.

• Her maternal grandmother has glaucoma.

• She has BCBS and Davis Vision• Is this a wellness exam or a medical exam?

Technical:The reason for the visit is the patient wants her contact lens RxThis is a wellness routine visit and Davis Vision is the payer

Practical:With a better case history, it could be either

Reality:Do wellness and CL evaluation, billing Davis VisionBring patient back for medical exam (physician direction)

Technical vs. Practical vs. Reality

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§ Bill wellness payer for wellness care, blow off medical billing § Bill medical payer for the medical care, blow off wellness care§ Bill wellness payer for examination, medical payer for diagnostic tests§ Bill medical payer for the medical care and wellness payer for the

wellness care on the same visit (KNOW THE RULES)§ Bill medical payer for the medical care, manage it, have patient return

for wellness care and bill wellness payer for wellness care – or vice versa (my favorite)

All fine, all legal

Remember Fifty Ways to Leave Your Lover?

Quick Review

o New patient comes in with EyeMed and Aetna o Stating they just want new glasses and have no problems o His/her father went blind from glaucomao He/she had a retinal hole repaired five years ago o He/she takes Topomax for migraines o But this is a vision examination because the reason for the visit is to get a new

glasses prescription?

Back to this reason for the visit thing

YES!

$Multiple reasons for the visit$The case history never ends$Physician directed $Patient directed reasons for the visit

So let’s talk about ways to deal with this seemingly crazy rule!

$You’ve all heard it for years ¬ Did you know the real importance of that statement has to do with justifying your

examination type based on medical necessity?

$This allows you to generate medical symptoms as well as MULTIPLE medical symptoms

$There is the difference between conducting a never ending case history¬ Which is good patient care

¬ “Turning an examination medical” is insurance fraud

The Case History Never Ends

$Physician directed“Physician directed visit for six month evaluation of glaucoma. Order 24-2 OU.”

$Patient directed“Dr. Smith requests comprehensive evaluation for potential ocular complications of Ms. Jones’ diabetes”

-OR-“Ms. Jones requests comprehensive evaluation as she is concerned about effect of diabetes on her eyes”

“Directed” Examinations

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Patient Directed Is NOT

$Dr. Smith (PCP) requests comprehensive evaluation for potential ocular complications of Ms. Jones’ diabetes

$BUT

$I want you you to bill my Vision Benefit Plan

Questions?

Thank you!