Cracking The Code - Texas Optometric Associationtexas.aoa.org/Documents/TX/2015 Convention/OD...

Cracking The Code: Clinical Case Management & Medical Record ComplianceTOA ‐ 2015

J. Rumpakis, OD, MBAPractice Resource Management, Inc. – [email protected]

www.JustAskJohn.info – www.CodeSAFEPLUS.comwww.PRMI.com – WhatsMyPracticeWorth.com

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© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBADUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.

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Cracking The Code

Clinical Case Management &Medical Record ComplianceSCO – Destination CE 2015 John Rumpakis, OD, MBA

Practice Resource Management, Inc.

© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.

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John Rumpakis, OD, MBA

Dr. Rumpakis is currently President & CEO of Practice Resource

Management, Inc., a firm that specializes in providing a full array of

consulting, appraisal, and management services for healthcare

professionals and industry partners. He has developed some of the

leading Internet‐based software applications for the medical/eye care

field such as CodeSAFEPLUS.com® (www.CodeSAFEPLUS.com), the

industry leading cloud‐based CPT & ICD Code Data and Information

Service, and offers personal medical coding consultation through

JustAskJohn (www.JustAskJohn.info). He is also the founder of Opt‐ED®

Professional Continuing Education (www.Opt‐ED.com) which creates and

delivers top tier continuing education around the country as well as Opt‐

IN® which provides optometric marketing and promotional services.

Named the Chief Medical Coding Editor for Review of Optometry

& Optometric Management, he has been extensively published on

the topics of third party coding & billing, strategy development

and execution, practice management, team building, maximizing

effectiveness and profitability, including the textbook “Business

Aspects of Optometry”. Dr. Rumpakis is a popular lecturer both

nationally and internationally. In addition to having had a

successful solo practice, Dr. Rumpakis developed the practice

management curriculum at Pacific University College of

Optometry and taught optometric & medical economics there for

over a decade.

A 1984 graduate of Pacific University College of Optometry, he

served as a volunteer for the AOA for near 17 years and sits on

numerous advisory boards, and board of directors for companies

both in and out of the ophthalmic industry.

Chief Medical Clinical Coding Editor – Review Of Optometry & Optometric Management

Financial Disclosures – John Rumpakis, OD, MBA

• Alcon Laboratories• Carl Zeiss Meditec• Optos• Vistakon• CooperVision• Maculogix• EMRLogic• TearLab• Freedom‐Meditech

• Allergan

• Beaver‐Visitec

• OfficeMate

• Maximeyes

• Luxottica

• MacuRisk

• Paragon


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• Eye‐Tel Imaging

• Bausch & Lomb

• Essilor of America

• Wal‐Mart

• Macuscope

• Topcon

• CyclopsEMR

• RevolutionEHR

• VisionWeb

• Opticare

• United Health Care

• Vision Source

• Bio‐Tissue

• ECRVault

I Am A Project Based Consultant & Have Received Honoraria From:(Partial Listing)

JustAskJohn – Personalized Medical Coding Consultation (www.JustAskJohn.info) CodeSAFEPLUS (www.CodeSAFEPLUS.com)Founder – Opt‐ED, Professional Optometric Continuing EducationFounder – Opt‐IN, Optometric Marketing & PromotionsWhatsMyPracticeWorth.com ‐ Online Practice Appraisals

•ArcticDX•Modernizing Medicine

•Annidis

•Kowa Optimed

•HeartSmart

•Diopsys

•Nicox




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Disclosures• All fees represented within this presentation are the 2015 Medicare National Average Maximum Allowable Reimbursements for each procedure listed as of February 20th, 2015.

• All information regarding policies, procedures, guidelines and definitions is current as of February 20th, 2015.

• Each viewer is responsible to be current in their own geographical jurisdiction interpretation of policies, procedures, guidelines and definitions prior to implementation within their own practice.

• The coding examples contained this presentation are examples only and each practitioner should apply these coding guidelines to what is actually recorded in the patients’ medical record before submitting any claim to a third party carrier.


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Learning Objectives• Clinical Grand Rounds – Understanding That Your Medical Record

Is Nothing More Than An EXTENSION OF YOUR CLINICAL CARE• The Medical Practice Environment• Audit Triggers & Prevention• Definitions

o Medical Necessity & The Chief Complaint• The Resource Based Relative Value System (RBRVS)

o Relative Value Units & Geographic Practice Cost Index• The ICD‐10

o ICD Changes – The Move From ICD‐9 to ICD‐10• Examination Services

o The Routine Eye Exam S Codes vs. 920XX codes vs. E/M codes

o The Ophthalmic Coding Guidelines – 920XX codes Compliance Issues and the medical record

o Demystifying E/M Coding Guidelines – 992XX codes 1995 E/M Guidelines 1997 E/M Guidelines

◦ Compliance issues and the medical record

• How To Translate The Exam Performed Into Coding Languageo Scoring The E/M Encountero Audit triggers and prevention

• Special Ophthalmic Testing – 2015 Update• Interpretive Report requirements• The ABN & NEMB – The Official Method of Notification

o Understanding the GX, GA, GZ and GY modifiers• The Rules Surrounding Ocular Surgical Procedures

o Appropriate Use of Modifiers • Local Coverage Determinations

o What is an LCDo Implications of LCD’so What LCD’s mean for coding compliance Medical necessity – Documentation Issues/Proof Covered diagnoses Recording requirements

• CMS’s Correct Coding Initiativeo What are the CCI Editso Column 1/Column 2 Codeso Mutually Exclusive Codeso Appropriate use of modifiers with the CCI Edits

• Factors For Success – John’s Top Twelveo Implementation & Integration Guidelines

• Identifying Obstacles & How To Overcome Them


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2015 Coding Requires 2015 Rules•Get Your Resource Material

oBy Book CPT 2015 ICD‐9 2015 HCPCS Level II 2015

•Or Get Everything Updated AUTOMATICALLYoOnline Cloud‐Based Resourceswww.CodeSAFEPLUS.com & www.JustAskJohn.info


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Questions About Today? – Email Me

[email protected]


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So… I know how to do it, but…HOW DO I MAXIMIZE THERETURN ON MY INTELLECTUAL PROPERTY?

If I Don’t Understand IT & Practice IT

IT May Be Taken Away


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Your Practice Is Like A Bucket


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Medical Eye Care Revenue

Contact Lens Drop Outs

Refractive & Contact Lens Revenue

Patients Going Elsewhere For Medical Eye Care




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Avoiding The Race To Zero…


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Reimbursement (Income)

Practice ProfitPatient Volume (Exams per hour)


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The trend is clear that we are shifting to a benefit structure that is borne by the recipient of the care, rather than a third party provider.

But John, I’m So Confused…EVERYBODY’S AN EXPERT??? THERE ARE SO MANY DIFFERENT PEOPLE THAT SAY SO MANY DIFFERENT THINGS…


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TRANSPARENCY


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Important Definitions

FRAUD

•When someone intentionally falsifies information or deceives Medicare.

ABUSE

•When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs, improper payments, or services that aren’t medically necessary.


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The Only Difference BetweenFraud & Abuse Is Intent.

http://www.cms.gov/Outreach‐and‐Education/Training/CMSNationalTrainingProgram/Downloads/2013‐Fraud‐and‐Abuse‐Prevention‐Workbook.pdf

CMS Fraud Detection ‐ Past & Present

PAST

• Providers suspected of fraudulent activity were put on prepay review, sometimes indefinitely

• CMS initiated overpayment recovery• Law enforcement determined if an arrest is appropriate

PRESENT

• Denies individual claims• Its contractors use prepay review as an investigative technique

• Revokes providers for improper practices• Collaborates with law enforcement before, during and after case development

• Addresses the root cause of identified vulnerabilities


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http://www.cms.gov/Outreach‐and‐Education/Training/CMSNationalTrainingProgram/Downloads/2013‐Fraud‐and‐Abuse‐Prevention‐Workbook.pdf




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The Government RecoveryIs Hitting Records!


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Former Optometrist Sentenced in Medicaid Fraud Case

FOR IMMEDIATE RELEASE : Wednesday, December 5, 2012CONTACT: Sara Rabern (605)773-3215

PIERRE, S.D.- Attorney General Marty Jackley announced today that Cary Stephen Feldman, 60, Spearfish, was sentenced to serve 15 years in prison for committing Medicaid fraud.

Seventh Circuit Court Judge Janine M. Kern suspended the execution of sentence on several conditions. Judge Kern ordered Feldman to serve 180 days in jail and ordered him to pay a total of $363,049.90 in restitution to Medicaid and Medicare. Feldman turned over a coin collection with an estimated value of $157,000, and paid an additional $80,000 to the government, so his remaining restitution balance is $126,049.90. Feldman was also ordered to serve 300 hours of community service, pay costs of $712.20 to the State and court costs of $208. Feldman allowed the South Dakota Board of Optometry to revoke his license in October.

Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a class 4 felony, and making false claims, a class 5 felony, pursuant to a plea agreement reached with the State. Feldman admitted that he knowingly and intentionally submitted false claims to the South Dakota Medicaid program and to Medicare. Feldman admitted that he submitted claims to Medicaid and to Medicare for consultation services, even though he had not provided such services. Feldman began submitting the false claims in late 2008, and continued until early 2012.

The case was investigated and prosecuted by the South Dakota Medicaid Fraud Control Unit, with assistance from the South Dakota Department of Social Services, the federal Department of Health and Human Services Office of Inspector General, the South Dakota Division of Criminal Investigation, the Spearfish Police Department, the Rapid City Police Department, the Pennington County Sheriff’s Office, the Pennington County Office of State’s Attorney, the Minnehaha County Sheriff’s Office, and the South Dakota Office of United States Attorney.

Seventh Circuit Court Judge Janine M. Kern ordered him to pay a total of $363,049.90 in restitution to Medicaid and Medicare. Feldman allowed the South Dakota Board of Optometry to revoke his license in October.

Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a class 4 felony, and making false claims, a class 5 felony, pursuant to a plea agreement reached with the State. Feldman admitted that he knowingly and intentionally submitted false claims to the South Dakota Medicaid program and to Medicare. Feldman began submitting the false claims in late 2008, and continued until early 2012.

The case was investigated and prosecuted by the South Dakota Medicaid Fraud Control Unit, with assistance from the South Dakota Department of Social Services, the federal Department of Health and Human Services Office of Inspector General, the South Dakota Division of Criminal Investigation, the Spearfish Police Department, the Rapid City Police Department, the Pennington County Sheriff’s Office, the Pennington County Office of State’s Attorney, the Minnehaha County Sheriff’s Office, and the South Dakota Office of United States Attorney.


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Medicare Urges Seniors To Join The Fight Against Fraud

In mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states.

Update on CMS’ Anti‐Fraud EffortsThe Affordable Care Act has enabled CMS to expand efforts to prevent and fight fraud, waste and abuse.Over the last four years, the Obama administration has recovered over $14.9 billion in healthcare fraud judgments, settlements, and administrative impositions, including record recoveries in 2011 and 2012.

Since the Affordable Care Act, CMS has revoked 14,663 providers and suppliers’ ability to bill in the Medicare program since March 2011. These providers were removed from the program because they had felony convictions, were not operational at the address CMShad on file, or were not in compliance with CMS rules.

In 18 states, the number of revocations has quadrupled since CMS put the Affordable Care Act screening and review requirements in place, as well as the implementation of proactive data analysis to identify potential license discrepancies of enrolled individuals and entities. These efforts are ensuring that only qualified and legitimate providers and suppliers can provide health care products and services to Medicare beneficiaries.

June 6, 2013 – Press Release




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Ripped From The Headlines• CMS Proposes New Safeguards and Incentives to Reduce Medicare Fraud

• On April 24, 2015 CMS issued a proposed rule that would increase rewards paid to Medicare beneficiaries and others whose tips about suspected fraud lead to the successful recovery of funds to as high as $9.9 million. In addition, a new funding opportunity released this month supports the expansion of Senior Medicare Patrol activities to educate Medicare beneficiaries on how to prevent, detect, and report Medicare fraud, waste, and abuse. The proposed rule would also strengthen certain provider enrollment provisions including allowing CMS to deny enrollment of providers who are affiliated with an entity that has unpaid Medicare debt, deny, or revoke billing privileges for individuals with felony convictions, and revoke privileges for providers and suppliers who are abusing their billing privileges.

• These proposed changes will support the administration’s comprehensive approach to program integrity, including the work being done with the Health Care Fraud Prevention and Enforcement Action Team, a joint effort between HHS and the Department of Justice to fight health care fraud. This joint effort recovered a record $4.2 billion in taxpayer dollars in fiscal year 2012.


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On April 24, 2014 CMS issued a proposed rule that would increase rewards paid to Medicare beneficiaries and others whose tips about suspected fraud lead to the successful recovery of funds to as high as $9.9 million. In addition, a new funding opportunity released this month supports the expansion of Senior Medicare Patrol activities to educate Medicare beneficiaries on how to prevent, detect, and report Medicare fraud, waste, and abuse.

The proposed rule would also strengthen certain provider enrollment provisions including allowing CMS to deny enrollment of providers who are affiliated with an entity that has unpaid Medicare debt, deny, or revoke billing privileges for individuals with felony convictions, and revoke privileges for providers and suppliers who are abusing their billing privileges.

And It’s Not Just CMS We Need To Worry About!


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What Is A “Red Flag” ThatTriggers An Audit?•Using codes under review by the OIG•Not reviewing your submitted claims against recovery audit issues•Abusing codes•Aberrant or inconsistent billing patterns•Maximizing revenue without sufficient documentation•Cloning of documentation•Not understanding definitions of modifiers and inappropriate use of modifiers


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What Else Should I Worry About?•New Rules Implemented In 2013 & Continued Into 2015:

oMultiple Procedure Payment ReductionoPlace of Service Codeso Legibility of Medical RecordsoNew Claim Submission GuidelinesoSpecial Ophthalmic Procedures – Self ReferraloCoding The Sequester

•OIG 2015 Work Plan•OIG Strategic Plan, 2015 ‐ 2018


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How You Create Your Medical Record Matters!THERE ARE LEGAL IMPLICATIONS OF HOW YOURECORD YOUR ENCOUNTER


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Fundamental Principles Are IMPORTANT!


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What do you do?(hint… think evidence based medicine)

What does this patient need?(hint… not what do you want to do)

What is in the patient’s best interest?




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Medical Necessity Is…“Services or supplies that are proper and needed for the diagnosis or treatment of the patient’s medical conditions, are provided for the diagnosis, direct care and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or the physician.”


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Source: www.Medicare.gov

So What Exactly Does That Mean?

The medical record must clearly demonstrate that the service, procedure, or test ordered & performed was absolutely

necessary in order to diagnose, treat, or monitor the treatment

of the patient’s condition.


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Keep The Order In MindIt’s As Easy As 1, 2, 3.Using The CPT & ICD System Is A Legal Requirement ‐‐ So learn to do it properly.

1. Always provide the Standard of Care to the patient2. Tell the medical record what you did and why you did it3. Then accurately translate what you did with the patient into CPT & ICD

language for the insurance carrier and your PM system.

o Never code first, then do testing just to reach the levelthat specific code requires

This approach would not support the concept of Medical Necessity that is required by third party carrier rules and guidelines


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E&M Medical Necessity ‐Medical Necessity of E&M Services• Section 1862(a)(1)(A) of the SSA, “Exclusions From Coverage and Medicare as Secondary Payer” does not include expenses acquired for items and services which are not deemed necessary for the diagnosis or treatment of illness or injury. This applies to all services.

• CMS IOS Publication 100‐04, Chapter 12, Section 30.6.1 states:“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”


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CPT CODEERROR RATE (PERCENT)

99215 70.9%

99214 69.6%

99223 78.7%

99233 68.5%

SERVICE-SPECIFIC PREPAYMENT REVIEWS OF EVALUATION AND MANAGEMENT SERVICESNational Government Services will be conducting service-specific prepayment reviews on the following CPT codes targeting E&M services for JK Part B providers:•99214•99215•99223•99233A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred to as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to:

•Physician/nonphysician practitioner’s progress notes,•Orders,•Medication records,•Procedure/operative reports,•Relevant diagnostic/operative reports or documentation of time that would assist in supporting the service(s) submitted

The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.Providers can assist in this process by:

•Reviewing all contractor publications and LCDs•Understanding Medicare coverage requirements•Ensuring office staff and billing vendors are familiar with claim filing requirements•Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines•Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request)•Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed

Posted 05/07/14

Reports from June 2013 through March 2014 show the following

CPT code error rates

71© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA

DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.




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Office Of Inspector General – 2014 Interim ReportOIG Report: Documentation Coding Errors Costing Medicare Billions• Posted on May 29,2014

• According to a new OIG report, documentation coding errors related to routine patient evaluation and management (E/M) visits are costing Medicare billions of dollars in improper payments a year. The investigation found that nearly $7 billion dollars in improper payments were made in 2010 alone. Most of the losses were the due to bills that were incorrectly coded and/or lacking documentation; 42% of claims for E/M services in 2010 were incorrectly coded and 19% lacked proper documentation.


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Your Money Is At Risk•The government is actively auditing providers and recouped over $4.3 billion in overpayments in 2013

•Approximately 21% of claims are being over‐coded putting your revenue at risk

•Audits typically find 8% of claims are under‐coded leaving money on the table


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Medical Carriers &Medical NecessityCARRIERS GENERALLY DEFINE IT FOR US!


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What Is A NCD?• An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs.

• If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LMRP).

• Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims‐processing contractors. That issuance, which includes an effective date and implementation date, is the NCD.


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What Is A LCD?•An LCD, as established by Section 522 of the Benefits Improvement and Protection Act, is a decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary‐wide or carrier‐wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

•The difference between LMRP’s and LCD’s is that LCDs consist only of "reasonable and necessary" information, while LMRP’s may also contain category or statutory provisions.


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What Happens If TheCarrier Doesn’t Have A Policy?•But, sometime carriers will not have a specific policy regarding the indications of medical necessity, nor a list of covered diagnoses or utilization guidelines that you can refer to.

•When this is the case, then the prevailing CPT definition and guidelines in combination WITH YOUR MEDICAL EXPERTISE become the defensible rule.


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Or What Happens If The Patient Is Paying?•If the patient is paying out of pocket and it is a separate distinct financial transaction where the carrier is NOT involved (i.e. balance billing), then you are free to do what you and the patient agree to.


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Medical Plans Vs.Refractive PlansWHAT’S THE DIFFERENCE?


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Refractive Plans•Do patients need a reason to see you?

o Do they need to have something wrong with them?

•What conditions have to be met?o Policy in forceo Coverage eligibilityo Participating provider

•What about duplicative coverage?o Who’s choice is it??

•My doctor always wants to bill medical if they find something


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Rule Number OneQUESTION:WHAT IS THE FIRST THING THAT MUST BE PART OF EVERY MEDICAL VISIT?

Answer:

A Chief Complaint


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So What Can Possibly Be New With A Chief Complaint?


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Cloned DocumentationThe word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter.

•Palmetto GBA ‐ Last updated on 11/06/2012


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Cloned Documentation• Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

•Palmetto GBA ‐ Last updated on 11/06/2012


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Cloning UpdateA Renewed Interest By The OIG


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The OIG said that the ability to "clone" chart notes from a previous patient encounter to help document the next one can help physicians work more efficiently, but also invite fraud, especially if no one edits the cloned information to make sure it's accurate and up to date. Government officials are worried that many physicians bill for higher levels of evaluation and management (E/M) services than warranted by cloning dense blocks of old patient information.

Patients Are Not Expected To Be The Expert – WE ARE!

WHY? ‐ THINK OF THE THREE E’S

EDUCATION, EXPERTISE, & EXPERIENCE


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Why Is The Patient In Your Office?There are only THREE ways that the patient ends up in your practice.

1. They initiate the appointment by phone call, email, online booking.2. You initiate the appointment by telling them to return to the office

for a specific reason.3. Other Physician initiates the appointment by telling them to make

an appointment for a specific reason.

• Once we know who initiated the encounter we can now properly determine the Chief Complaint.


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There Are TWO Ways AChief Complaint Requirement Is Met

Physician Directed(reason for visit)

Patient Directed


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The Chief ComplaintThe Medicare Carriers Manual, Part 3 §2320 reads:

"The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition."


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Your Contact Lens Patient With Ocular Allergy


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Differential Diagnosis•Dry eye presents with grittiness, burning and signs of surface disease

•Infection shows discharge•Allergy itches + family history•Urban allergy ‐ vasomotor conjunctivitis varies with environmental triggers


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Ocular AllergyPatient Presentation•New Patient•43 y/o AAF

o VSP (refractive insurance)o Blue Cross (medical insurance)

•Presents witho Ran out of CL’s – New Insuranceo Dx Blur – O.D. > O.S. (refractive in nature)o Seasonal allergies discovered during case history, but not primary reason for visit Claritin OTC, QD, Visine AC per PI


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Coding Concepts

•New vs. Established

•Chief Complaint

•Medical vs. Refractive

•Contractual Obligations

•Additional Services Covered




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Coding The Comprehensive ExamDiagnosis: 367.1, Myopia

Dates of Service

Place of Service

Type of Service

Procedures, Services, Supplies (Explain Unusual Circumstances)

Diagnosis Code Charges

Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/17/2015 11 92004 1 $148.83 12 1/17/2015 11 92015 1 $19.93 13456


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Initiating A Treatment Plan• What would be the Standard of Care?• Communicate with patient• Complete the medical record• Prescribe a medication• Set follow‐up visit


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Ocular Allergy – 1 week later


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Diagnosis: 372.14, Allergic Conjunctivitis, Chronic

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo





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Why 99213?

99211 99212 99213 99214 99215

History 0 1 2 3 4

Exam 0 1 2 3 4

Decision Making

0 1 2 3 4


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What about the 92012 code?•Use of the 92012 code could be perfectly acceptable – if & when the medical carrier accepts them as medical in nature vs. refractive and if the code definition is met.

oYou Often Want To Choose It Because Less documentation requirements Increased reimbursement

oBUT ‐


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CPT 2015 Definition:

“… describes an evaluation of a new (condition) or an existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis.

Ocular Allergy – 6 months later


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Diagnosis: 372.14, Allergic Conjunctivitis, Chronic

Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY

To MM/DD/YY CPT-HCPCS - Modifier

1 7/23/2015 11 99213 1 $72.68 123456




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Ocular AllergyProfitability Per Hour

$780


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Lost Opportunity Costs?•Did the one week allergy follow‐up cannibalize another annual eye exam opportunity?

•NO! – Why?oAllergy visit – 5 minutesoCan be double‐booked with an annual examinationoMaximizes revenue per Dr. hour


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Key Concepts•Allergy encounter was driven by annual exam•Easy to diagnose•Easy to treat•Not a drag on schedule•Builds other areas of business


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Just What IS The Value Of Your “Intellectual Property”?


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John’s Golden Rule

You have to follow the rules…

Even if theyeconomically benefit you!


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Does Medical Coding Seem Like A Foreign Language?IT DOESN’T HAVE TO BE… WE JUST HAVE TO SPEAK THE LANGUAGE


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Understanding Code DifferencesWITHIN THE HCPCS SYSTEM EACH CODE SUBSET HAS IT ’S OWN IMPLIC IT PURPOSE

…AND IT ’S OWN FORMAT


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Key ConceptsTerm Definition Code Format Ownership

HCPCS ICPT‐4; Current Procedural Terminology, 4th Edition(HCPCS Level I Codes)

12345Always Five Digits

AMA1

HCPCS IIHealthcare Procedural Coding System Level II Codes

A‐V1234Always Alphanumeric

AMA1

HCPCS IIIHealthcare Procedural Coding System Level III Codes (Emerging Technology)

1234TAlways Alphanumeric

AMA1

ICD‐9‐CMInternational Classification of Disease, 9th Edition

123.45

Generally Five DigitsWHO2


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1: http://www.ama‐assn.org/ama/pub/category/3884.html

2: http://www.who.int/classifications/icd/en/

Health Care ProceduralCoding System (HCPCS)Level One HCPCS

Level Two HCPCS

Level Three HCPCS

CPT Procedural Codes

Non‐CPT Codes for Materials, Services & PQRS

Emerging Technology & Temporary Use Codes


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Health Care ProceduralCoding System (HCPCS)•Level One HCPCS Are The CPT®‐4

oCurrent Procedural Terminology – 4th Edition

•CPT Codes Are Always…oOne Five Digit Code Plus Up To Four, 2 Digit Modifiers

12345‐AB‐CD‐EF‐GH


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Initial Procedure

1st Modifier2nd Modifier

Health Care ProceduralCoding System (HCPCS)

•Level Two ‐ National Codes for Materials, Services & PQRS

•Level Two Codes: 5 Digit Alpha‐Numeric


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Level II DesignationA‐V1234

Health Care ProceduralCoding System (HCPCS)•Level Three ‐ Emerging Technology & Temporary Use Codes

•Level Three Codes: Category III codes are temporary codes for emerging technology, services, and procedures. Category III codes consist of four numbers followed by the letter "T."


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Category III Designation 1234T




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Key Concepts To ReimbursementTerm Definition Resource

RBRVSResource BasedRelative Value System

CMS*

RVU Relative Value Unit CMS*

GPCIGeographic PracticeCost Index

CMS*

Conversion FactorA “Dollar” Multiplier In The Reimbursement Calculation

CMS*

Maximum Allowable Reimbursement

Geographically Adjusted RVU’s X The Conversion Factor

CMS*


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* www.cms.hhs.gov

Reimbursement Fundamentals•RBRVS•Determines the Maximum Allowable Fee

oFor Every ProcedureoFor Every Carrier•Relative Value Units Are Based On:

oAmount Of Work Associated With ProcedureoPractice Overhead Expenses Associated With ProcedureoMalpractice & Professional Liability Costs Associated With Procedure

oGeographic Location Adjustments GPCI – Geographic Practice Cost Indices


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Calculating ReimbursementsIT’S NOT ROCKET SCIENCE… JUST MATH


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Procedure Relative Value Units

CPT Code Descriptions WorkPractice Expense Malpractice

92014 Eye exam & treatment 1.1 1.41 0.03

92015 Refraction 0.38 1.49 0.01

92020 Special eye evaluation 0.37 0.34 0.01

92070 Fitting of contact lens 0.7 1.07 0.02

92083 Visual field examination (s) 0.5 1.43 0.02


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Geographic PracticeCost Index (GPCI’s)

Locality Name Work GPCI PE GPCI MP GPCI

Alabama 1 0.846 0.752

Alaska 1.017 1.103 1.029

Arizona 1 0.992 1.069

Arkansas 1 0.831 0.438

San Francisco, CA 1.06 1.543 0.651

Oakland/Berkley, CA 1.054 1.371 0.651

Santa Clara, CA 1.083 1.54 0.604

Los Angeles, CA 1.041 1.156 0.954

Anaheim/Santa Ana, CA 1.034 1.236 0.954


123

The Conversion FactorA conversion factor is nothing more than a “Dollar Multiplier” in determining the Maximum Allowable

Reimbursement for each CPT code

Total Geographically Adjusted RVU’sX The Conversion Factor

= The Maximum Allowable Reimbursement


124




27

Medicare Conversion Factors

$22

$24

$26

$28

$30

$32

$34

$36

$38

$40

2002 2004 2006 2008 2010 2012 2014

Proposed

Final


125

ICD‐9‐CMINTERNATIONAL CLASSIFICATION OF DISEASE– NINTH EDITION CLINICAL MODIFICATION


127

ICD‐9‐CM Codes•International Classification Of Disease, 9th Edition•Owned By The World Health Organization•Consistent On A Global Basis

•Diagnosis Codes: Single 5 Digit Code with Decimal Point

123.45


128

Can Also Be Single Digit

Always use highest level of specificity




28

ICD‐9‐CM Codes•The critical relationship between an ICD‐9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure

•List primary diagnosis code first (systemic – always first)o Keep in mind that ICD‐9 rules prevent you from using the patients symptoms as a diagnosis if you know the cause of the symptoms

•Link specific procedures to appropriate diagnosis on CMS 1500 form

•Stay away from diagnosis codes: XXX.9•There are still legitimate 3 and 4 digit ICD‐9 codes to use


129

ICD‐9 Critical Points•Having a diagnosis that supports Medical Necessity is REQUIRED for coverage

•Having ONLY a covered diagnosis is not enough to survive an audit unless you have properly established Medical Necessity in the medical record


130

Remember These Changes That Took Place In 2012?•There are eight new codes and one revised code in this category.

o 365.01 Revised – Open angle with borderline findings, low risko 365.02 New – Anatomical narrow angle, primary closure suspecto 365.05 New – Open angle with borderline findings, high risko 365.06 New – Primary angle closure without glaucoma damageo 365.70 New ‐ Glaucoma stage, unspecifiedo 365.71 New –Mild stage glaucomao 365.72 New –Moderate stage glaucomao 365.73 New – Severe stage glaucomao 365.74 New – Indeterminate stage glaucoma


131




29

How You Should Be Coding GlaucomaIF YOU USE ANY OF THE FOLLOWING DIAGNOSIS CODES

•365.10•365.11•365.12•365.13•365.20•365.22

THEN YOU MUST ALSO USE ONE OF THESE DIAGNOSTIC CODES IN ADDITION

• 365.70 New ‐ Glaucoma stage, unspecified• 365.71 New – Mild stage glaucoma• 365.72 New – Moderate stage glaucoma• 365.73 New – Severe stage glaucoma• 365.74 New – Indeterminate stage glaucoma


132

•365.23•365.31•365.52•365.62•365.63•365.65

ICD‐10‐CMReady Or Not…

INTERNATIONAL CLASSIFICATION OF DISEASETENTH EDITION, CLINICAL MODIFICATION


133


134




30

ICD‐10•ICD‐10 is used world‐wide•All major countries use ICD‐10 except the US and Italy

oUK (1995), France (1997), Australia (1998), Germany (2000), & Canada (2001)

•Published by World Health Organization (WHO)oUS obligated to classify morbidity statistics with ICD‐10 by world treaty


135

What’s Different Between ICD‐9 & ICD‐10?

•68,000+ codes•Diseases and conditions and causes grouped:

oCommunicable diseasesoGeneral diseases that affect whole bodyo Local diseases arranged by siteoDevelopment of diseaseso InjuriesoExternal causes


136


•Harmonized with other classificationsoDSM‐IV ‐mental health disorderso ICDO‐2 ‐ cancer registriesoNursing

•Removed relationships with procedures/procedure codes (in some applications – still tied, where appropriate to LCD’s)

•Revised diabetes codes to be consistent with ADA categories


137




31

What’s Different Between ICD‐9 & ICD‐10

•Increased Specificity For:o Laterality (differentiation of right versus left versus bilateral)o Injury Codes Code extensions for external causes of injury Code extensions for injuries

oPostoperative complications & phases of treatmentoTrimester informationoAlcohol and substance abuse


138

Bottom Line – It’s Going To Be Different!


139

ICD‐9 & 10 Partial Code Freeze•The last regular, annual updates to both ICD‐9‐CM and ICD‐10 code sets were made on October 1, 2011.

•On October 1, 2012 and October 1, 2013 there were only limited code updates to both the ICD‐9‐CM and ICD‐10 code sets to capture new technologies and diseases.

•On October 1, 2014, there were only limited code updates to ICD‐10 code sets to capture new technologies and diagnoses.o There will be no updates to ICD‐9‐CM, as it will no longer be used for reporting. – 2015 will be last year of updates

•On October 1, 2015, regular updates to ICD‐10 will begin.


140

503(a) of Pub. L. 108‐173




32

ICD‐10‐CM Codes (October 1, 2015)•An ICD‐10 code:•Is three to seven digits long •Begins with an alphabetic character •Has a numeral as the second digit •Includes alpha or numeric digits as the third through seventh characters

•Decimal after first three characters•Not case sensitive•Pay attention! Watch for Ø for 0 to differentiate from O•Has high levels of differentiation of right vs. left vs. bilateral


141

The ICD ‐10 For The Eyes (Chapter 7)ICD‐10 Codes Eye Conditions (Categories)

HØØ‐HØ5 Disorders of the Eyelid, Lacrimal System, and Orbit

H1Ø‐H11 Disorders of the Conjunctiva

H15‐H22 Disorders of the Sclera, Cornea, Iris, and Ciliary Body

H25‐H28 Disorders of the Lens

H3Ø‐H36 Disorders of the Choroid and Retina

H4Ø‐H42 Glaucoma

H43‐H44 Disorders of the Vitreous Body and Globe

H46‐H47 Disorders of the Optic Nerve and Visual Pathways

H49‐H52 Disorders of the Ocular Muscles, Binocular Movement, Accommodation, and Refraction

H53‐H54 Visual Disturbances and Blindness

H55‐H57 Other Disorders Of The Eye and Adnexa

H59 Intraoperative and PostProcedural Complications and Disorders of the Eye and Adnexa, Not Elsewhere Classified


142


ICD‐9 Format

ICD‐10 Format


144

Category Etiology, Anatomical Site, Manifestation

Category Etiology, Anatomical Site,Manifestation & Severity

Extension




33

Structure Of The ICD‐10•Diabetic Retinopathy ICD‐10 E11.321 (Example)

E11.321© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA

DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.145

Endocrine, nutritional and metabolic diseases

Diabetes mellitus

Type 2 diabetes mellitus

Type 2 diabetes mellitus with ophthalmic complications

Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy

Type 2 diabetes mellitus with mild nonproliferativediabetic retinopathy with macular edema

Structure Of The ICD‐10(Clinical Example Later)The Placeholder

• Not every ICD‐10‐CM code with a seventh character has a sixth character—or even a fifth or fourth character for that matter.

• The letter “x” serves as a placeholder when a code contains fewer than six characters and a seventh character applies. The “x” also allows for future expansion of the codes.o When reporting ICD‐10‐CM codes, a placeholder must be added so the seventh character is in the correct position. Without this placeholder to ensure characters appear in the correct positions, codes are invalid.

• The location of the X within a code matters. When x is in the fourth, fifth, and/or sixth character, it appears lowercase and is a placeholder. When X is at the beginning of the code, it is uppercase and indicates the chapter.


146

Structure Of The ICD‐10(Clinical Example Later)The Seventh Character

• A ‐ Initial encounter. This describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. So, you can use “A” as the seventh character on more than just the first claim. In fact, you can use it on multiple claims.

• D ‐ Subsequent encounter. This describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery.

• S ‐ Sequela. The seventh character extension “S” indicates a complication or condition that arises as a direct result of an injury. An example of a sequela is a scar resulting from a burn.


147




34

Related To The Eye, But In Not In Chapter 7Exclusions:•Listed at the beginning of the Eye Chapter (Chapter 7)•Indicates condition or disease is found in a different chapter•Exclusions can pertain to:

o conditions during newborn period (PØØ‐P96)o some infectious and parasitic diseases (AØØ‐B99)o complications of pregnancy (OØØ‐O99)o congenital disorders (QØØ‐Q99)o diabetic and endocrine disorders (EØØ‐E9Ø)o trauma, injury, and poisoning (SØØ‐T98)o neoplasms (CØØ‐D48)


148

Special Symbols (Dagger & Asterisk)•(†) underlying cause or ae ology (note spelling ‐ Brit.)•(*) current manifestation• Always code dagger first, then asterisk

•Clinical Example:oHypertensive retinopathy (H35.Ø3…)oCode I1Ø (Essential (primary) hypertension) firstoCode H35.Ø33 (hypertensive retinopathy, bilateral) second


150

Additional Circumstances(Injury & Trauma)•Chapter 19•Organized by anatomical site, then type of injury•7th character required to specify number of the encounter (initial vs subsequent or follow‐up)

•Need to use Chapter 20 and indicate cause of injury (definite with “S” code, maybe for “T”)


151




35

Eye Injury & TraumaICD‐9 ICD‐10

930.0 Corneal Foreign Body T15.01XA – Foreign Body In Cornea, Right Eye, Initial Encounter

T15.01XD – Foreign Body In Cornea, Right Eye, Subsequent Encounter

T15.01XS – Foreign Body In Cornea, Right Eye, Sequela


152

Eye Injury & TraumaICD‐9 ICD‐10

918.1 Superficial Injury of Cornea S05.01XA – Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter

S05.01XD – Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Subsequent Encounter

S05.01XS – Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Sequela


153

Eye Injury & TraumaCause Of Injury (Chapter 20) ICD‐10

Tree Branch W22.8XX(A,D, Or S) – Striking Against or Struck By Other Objects, Initial (A), Subsequent (D), or Sequela (S)

Fingernail W5Ø.4XX(A,D, Or S) – Accidental Scratch By Another Person, Initial (A), Subsequent (D), or Sequela (S)


154




36

Eye Injury & TraumaSo Keep These Key Things In Mind

1. Classify the injury by anatomical site

2. Classify the injury by stage of visit Initial (A)

Subsequent (D)

Sequelea (S)

3. Classify the cause of the injury


155

Office VisitsDEFINING THE PHYSICIAN/PATIENT ENCOUNTER(THE #1 AUDIT TRIGGER)


156

OverviewEye Examinations – Office VisitsCode Set

Code Group

Class

Relative Value

Units

Level Of Reimbursement

Level Of Documentation

Billed To Medical

Insurance?

Acceptance By Medical Insurance?

Role In Medical Eye Care?

920XX Codes

HCPCS Level I (CPT)

Yes

Higher

92004 = Lower Yes Varied Varied

992XX Codes

HCPCS Level I (CPT)

Yes

Lower

99203 = Higher Yes Always High

S CodesHCPCS Level II

No Market Value Lower No None None

$108.39


157

$148.83




37

OverviewEye Examinations – Office Visits


158

Code Set

Code Group

Class

Relative Value

Units

Level Of Reimbursement

Level Of Documentation

Billed To Medical

Insurance?

Acceptance By Medical Insurance?

Role In Medical Eye Care?

920XX Codes

HCPCS Level I (CPT)

Yes

Higher

92012 = Lower Yes Varied Varied

992XX Codes

HCPCS Level I (CPT)

Yes

Lower

99213 = Higher Yes Always High

$85.68

$72.68

The Routine Eye ExaminationSO, WHAT DOES “ROUTINE” REALLY MEAN?


159

The “S” Codes•Although Medicare and other federal payers don't recognize the "S" codes, they can be useful for claims to some private insurers and other parties… o S0620 (for new patients)o S0621 (for established patients)

•Specifically describe routine well patient vision exams, including refraction.

•By performing a different level of service, you are required to use a different code, therefore are able to charge a separate fee.


160




38

A “S” Code Exam Is NOT ACOMPREHENSIVE EYE EXAMINATIONFOR PRIVATE PAY PATIENTS!


161

The Ophthalmic Office VisitsTHE COMPREHENSIVE EXAM & THE INTERMEDIATE EXAM


163

920x4 ‐ Comprehensive

•The service includes:o Historyo General medical observationo External examinationo Ophthalmological examinationso Gross visual fieldso Basic sensorimotor examination

•It often includes, as indicated:o Biomicroscopyo Examination with cycloplegia or mydriasis

o Tonometry


164

CPT 2015 Definition:“… describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session.

It always includes initiation of diagnostic and treatment programs.”




39

920x2 ‐ Intermediate

•The service includes:oHistoryoGeneral medical observationoExternal examinationoAdnexal examinationoother diagnostic procedures as indicated

•It often includes, as indicated:oBiomicroscopyoAnd may include the use of mydriasis for ophthalmoscopy


165

CPT 2015 Definition:

“… describes an evaluation of a new (condition) or an existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis

It always includes initiation of diagnostic and treatment programs.”

920XX & DilationDILATION IS NOT MANDATORY WITH ANY OF THE 920XX CODES


166

The Evaluation & ManagementOffice VisitsTHEY ARE NOT NEW ANYMORE!


167




40

Evaluation & ManagementCoding SystemNew Patient•99201•99202•99203•99204•99205

Established Patient•99211•99212•99213•99214•99215


168




169




170

Use CPT 99211, physician presence is not required, but he/she must have initiated the service as part of a continuing plan and must at least be in the office suite when each service is provided.

The use of 99204 & 99205 require a comprehensive history which is difficult for us to provide




41

E&M Frequency Data


171

New Patient E&M code 2002 2004 2006 2008 2010

99201 5% 4% 3% 3% 2%

99202 24% 22% 21% 19% 13%

99203 38% 40% 42% 43% 37%

99204 24% 26% 26% 27% 35%

99205 9% 9% 9% 8% 13%

Established Patient E&M code 2002 2004 2006 2008 2010

99211 6% 5% 5% 4% 4%

99212 15% 12% 11% 10% 9%

99213 54% 53% 51% 49% 46%

99214 22% 26% 30% 33% 36%

99215 3% 3% 4% 4% 5%

ER E&M code 2002 2004 2006 2008 2010

99281 1% 1% 1% 1%Less than

1%

99282 8% 6% 4% 3% 3%

99283 30% 28% 25% 22% 20%

99284 31% 30% 29% 29% 29%

99285 30% 35% 40% 44% 48%

Source: “Coding Trends of Medicare Evaluation and Management Services,” Dept. of Health and Human Services Office of Inspector General, May 2012

Elements of E/M Rationale•History•Examination•Medical Decision Making•Counseling•Coordination of Care•Nature of the Presenting Problem•Time


172

The Big Three…•History

oFour levels of history

•Physical ExaminationoWe are single system subspecialistsoFour levels of physical examination

•Medical Decision MakingoFour levels of medical decision making


173




42

Documentation of History• Problem Focused

o Chief Complainto 1 to 3 elements of History of Present Illness (HPI)

• Expanded Problem‐Focusedo Chief Complainto 1 to 3 elements of HPIo Ocular review of systems

• Detailedo Chief Complainto 4 elements of HPIo Ocular review of systems + 1 other systemo 1 specific item from past, family, or social history

• Comprehensiveo Chief Complainto 4 elements of HPIo Ocular review of systemso Review of at least 9 additional systemso 2‐3 specific item from past, family, and social history (est. vs. new)


174

Most CommonHPI Elements

•Location•Duration•Severity•Modifying Factors

Scoring A History ‐ HPI•History of Present Illness (HPI)•Location•Quality•Severity•Duration•Timing•Context•Modifying Factors•Associated Signs & Symptoms

•Briefo ‐ 1‐3 elements

•Extendedo ‐ 4‐8 elements or at least 3 chronic or inactive conditions


175

Scoring A History –Review Of Systems1. Constitutional2. Eyes3. Ears, Nose, Mouth & Throat4. Cardiovascular5. Respiratory6. Gastrointestinal7. Genitourinary

8. Musculoskeletal9. Integumentary10.Neurological11.Psychiatric12.Endocrine13.Hematologic/Lymphatic14.Allergic/Immunologic


Problem Pertinent is 1 system Extended is 2‐9 systems Complete is 10‐14 systems

How Are You Going To Get To 10?

176




43

Documentation of History• Problem Focused

o Chief Complainto 1 to 3 elements of History of Present Illness (HPI)

• Expanded Problem‐Focusedo Chief Complainto 1 to 3 elements of HPIo Ocular review of systems

• Detailedo Chief Complainto 4 elements of HPIo Ocular review of systems + 1 other systemo 1 specific item from past, family, or social history

• Comprehensiveo Chief Complainto 4 elements of HPIo Ocular review of systemso Review of at least 9 additional systemso 2‐3 specific item from past, family, and social history (est. vs. new)


177

Most CommonHPI Elements

•Location•Duration•Severity•Modifying Factors

Scoring A History ‐ PFSH

•Patient’s Past History•Family History•Social/Occupational History

•Problem Pertinento l question

•Completeo2 areas for Est Pto3 areas for New Pt

Past, Family & Social History


178

Scoring A HistoryPutting The Pieces Together

Level 1 Level 2 Level 3 Level 4

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

HPIBrief1‐3

Brief1‐3

Extended4‐8

Extended4‐8

ROS N/AProblem Pertinent1 area

Extended2‐9 areas

Complete10‐14 areas

PFSH N/A N/AProblem Pertinent1 area

Complete2 areas est3 areas new


179




44

Documentation of Physical Exam• Problem Focused

o Limited exam of the affected body area or organ systemso 1 to 5 elements of the eye exam documented

• Expanded Problem‐Focusedo Limited exam of the affected body area or organ system and other symptomatic or related organ systems

o 6 elements of the eye exam documented• Detailed

o Extended exam of the affected body area and other symptomatic or related organ systems

o 9 elements of the eye exam documented (can include M/S)• Comprehensive

o Complete single system specialty examo All elements of the eye exam plus mental status documented


180

Elements Of An Eye Exam (1997)1. VA’s2. EOM3. Confrontation Fields4. Adnexa

o Lidso Lacrimal glandso Lacrimal drainageo Orbitso Preauricular lymph nodes

5. Bulbar and palpebral conjunctivae6. Corneas

o Epitheliumo Stromao Endotheliumo Tear film

7. Pupils & Iriseso Shapeo Afferent pupilo Sizeo Morphology

8. Anterior Chambero Deptho Cellso Flare

9. Lenseso Clarityo Ant/post capso Cortexo Nucleus

10. IOP ‐ except in children and patients with trauma or infectious disease

11. Optic discso Sizeo C/D ratioo Appearanceo Nerve fiber layer

12. Posterior segmentso Retinao Vessels

13. Orientation14. Mood/Affect


182

992XX Codes & DilationDILATION IS MANDATORY WITH THE 992XX CODE IF THE TWO RETINAL ELEMENTS ARE USED TO COUNT TOWARDS LEVEL OF PHYSICAL EXAM, UNLESS MEDICALLY CONTRAINDICATED

Reference:1997 CMS Evaluation & Management Guidelines


183




45

Levels Of Physical ExamRemember The Key Numbers of 5, 6, 9, or Everything

•Any 5 elements or less = Level 1•Any 6 – 8 elements = Level 2•Any 9 – 13 elements = Level 3 (including mental status)•All elements = Level 4 (including mental status)


184

Medical Decision MakingDiagnostic & Treatment Options•Number of Diagnoses

•Number of Management Options

•1 is Minimal•2‐3 is Limited•4‐5 is Multiple•6+ is Extensive


185

Medical Decision MakingComplexity of Data•Diagnostic service ordered, planned, scheduled, or performed

•Review of diagnostic tests•Decision to obtain old records, or take additional history•Relevant finding from old records or additional history taken

•Discussion with other physician•Independent interpretation of previously taken images, or studies


186




46

Medical Decision MakingRisk Of Complications/Morbidity• Minimal ‐ One self limited or minor problem

• Low ‐ Two or more self limited or minor illnesses; One stable or chronic illness; One acute illness or injury; Uncomplicated injury or illness. Use of OTC medication.

• Moderate ‐ One chronic illness with mild complications; Two stable chronic Illnesses; An undiagnosed new problem (uncertain prognosis); Acute illness with systemic symptoms; Acute complicated injury. Prescription medication management.

• High ‐ One or more chronic illness with severe complications, Acute or chronic illnesses or injuries posing a threat to life, or an abrupt change in neurological status


187

Medical Decision MakingLevel 1 Level 2 Level 3 Level 4

Straightforward

Low Complexity

Moderate Complexity

High

Complexity

Number of Diagnostic &

Treatment Options

Minimal

(1)

Limited

(2‐3)

Multiple

(4‐5)

Extensive

(6+)

Amount & Complexity of Data

Minimal or None

(1)

Limited

(2‐3)

Moderate

(4‐5)

Extensive

(6+)

Risk of Complications &/or

Morbidity

Minimal

1 self limited

Low

2 SL, 1 C, 1A, OTC

Moderate

1CwC, 2 C, New, Rx

High

1C w/high comp, threat to life


188


Straightforward

Low Complexity

Moderate Complexity

High

Complexity


Treatment Options

Minimal

(1)

Limited

(2‐3)

Multiple

(4‐5)

Extensive

(6+)


Minimal or None

(1)

Limited

(2‐3)

Moderate

(4‐5)

Extensive

(6+)


Morbidity

Minimal

1 self limited

Low

2 SL, 1 C, 1A, OTC

Moderate

1CwC, 2 C, New, Rx

High



189




47


Straightforward

Low Complexity

Moderate Complexity

High

Complexity


Treatment Options

Minimal

(1)

Limited

(2‐3)

Multiple

(4‐5)

Extensive

(6+)


Minimal or None

(1)

Limited

(2‐3)

Moderate

(4‐5)

Extensive

(6+)


Morbidity

Minimal

1 self limited

Low

2 SL, 1 C, 1A, OTC

Moderate

1CwC, 2 C, New, Rx

High



190


Straightforward

Low Complexity

Moderate Complexity

High

Complexity


Treatment Options

Minimal

(1)

Limited

(2‐3)

Multiple

(4‐5)

Extensive

(6+)


Minimal or None

(1)

Limited

(2‐3)

Moderate

(4‐5)

Extensive

(6+)


Morbidity

Minimal

1 self limited

Low

2 SL, 1 C, 1A, OTC

Moderate

1CwC, 2 C, New, Rx

High



191


Straightforward

Low Complexity

Moderate Complexity

High

Complexity


Treatment Options

Minimal

(1)

Limited

(2‐3)

Multiple

(4‐5)

Extensive

(6+)


Minimal or None

(1)

Limited

(2‐3)

Moderate

(4‐5)

Extensive

(6+)


Morbidity

Minimal

1 self limited

Low

2 SL, 1 C, 1A, OTC

Moderate

1CwC, 2 C, New, Rx

High



192




48

Identifying Level of Service

99201 99202 99203 99204 99205

History 1 2 3 4 4

Exam 1 2 3 4 4

Decision Making

1 2 2 3 4


193

New Patient – Must meet or exceed 3 of 3 to qualify for that code level

(Grade To Lowest Of Three)

Identifying Level of Service

99211 99212 99213 99214 99215

History 0 1 2 3 4

Exam 0 1 2 3 4

Decision Making

0 1 2 3 4


194

Established Patient – Must meet or exceed 2 of 3 to qualify for code

(Grade To Middle Of Three)

So Which Code Do I Use?ONCE AGAIN, SIMPLY FOLLOW THE RULES…


206




49

Identifying The AppropriateCategory Of Service To Perform•Based upon patient’s presenting status

•What is theirchief complaint?

•Do they have coverage where there exists a contractual obligation?

•Category For Code Selection

•Ophthalmological 1•E/M Service 2•“S” Code 3


207

217© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA

DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED.

Special Ophthalmological Services


218




50

The CMS 1500 Form – NEW In 2014•Your LEGAL document submission

o You are attesting under penalties of perjury that everything is true and accurate

•Standard format accepted by all carriers for submitting claims•Understanding this form is essential to getting properly reimbursed and for following rules in claims submissions.

•Effective 1/1/2014, Grace Period 1/1 – 3/31, must use 4/1/2014

Let’s Take A Look219


What Are They?Definition:•Describes services in which a special evaluation of the part of the visual system is made, which goes beyond the services included under general ophthalmological services or in which special treatment is given.

•Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services.


220

CPT: Professional Edition, 2015. Pg. 565

Some Frequent Questions!•When can I do a special ophthalmic test?

o You can perform a special ophthalmic test on the same day as any office visit.

o They are a distinct and separate procedure and are not bundled into any examination services

•Can I do the tests when the doctor is not in the office?o Yes – but you do have to pay attention to Supervision Status

•Can I bill the test on the same day?o May have to use a modifier for some carriers

•Do I have to collect two co‐pays?•Can I order tests way ahead of time?


221




51

Key Learning Point•Interpretation and report by the physician is an integral part of the special ophthalmological services where indicated.

•Technical procedures (which may or may not be performed personally) are often part of the service, but should not be mistaken to constitute the service itself.

•New Rule For 2013 – Maintained In 2015o Self‐Referral For Special Ophthalmic Testingo C0‐16 EOB Claim Designator – Requires Physician Name & NPIin Box 17 of CMS 1500


222


Performing Additional TestsRoutine Procedures VS. Ordered Procedures•The chronology of your medical record is imperative

•Routine testing = standing orderso Never billable

•Ordered testingo Based upon medical necessityo Bill with office visit Use modifier when appropriate

o Be aware of specific code requirements & definitionso Generally require an Interpretive Report


223

How Do We Code Something That Is Different Than Its Defined Value?

Example – Fundus Photography (92250)•Active Code•Bilateral By Definition•Global Period Definition (XXX)

•Traditional Bilateral Use – 92250

•Unilateral Use – 92250 – 52 ‐ (RT or LT)


224

Base Code

Reduced Services

Laterality Indicator




52

How A Code Is Broken Down•Example•92134 – Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina.

•What Coding with modifiers meanso92134‐TC, means you only performed the technical componento92134‐26, means you only performed the professional component


225


How A Code Is Broken DownDefinitions – Modifiers ‐26 & ‐TC

• ‐26 Professional Component, Certain procedures are a combination of the a physician professional component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier ‐26

• ‐TC Technical Component, The technical component is the equipment and technician performing the test. This is identified by adding modifier “TC” to the procedure code identified for the technical component charge.


226

Introduced In 2013 – Maintained In 2015Multiple Procedure Payment Reduction

• Summary of Rule:• You will get 100% of the highest TC service, but each subsequent TC component will be reduced by 25% for all services performed on the same day.

• When established, the 2013 Physician Fee Schedule Final Rule indicated that CMS will monitor these tests to identify inappropriate changes in timing of the delivery of these diagnostic tests.

• In other words, if physicians start changing their practice and billing patterns to avoid the reductions, they will most likely be identified as an outlier which could result in an audit.


227




53

Why Does This Matter?•Let’s look at the reimbursement issues this raises

•Reimbursement as a whole code is the same as the sum total of both separate components

•General rule is that you are prevented from breaking apart if you are doing the test in your office.


228

CPT Code CPT Code CPT Code Before After

92134 92250 92083 MPPR MPPR

Professional Component (‐26) $28.92 $24.27 $28.20 $81.39 $81.39

Technical Component (‐TC) $16.40 $55.02 $36.43 $107.85 $94.64

Total $45.32 $79.29 $64.63 $189.24 $176.03

Total Reduction In This Example 7%

What Codes Are Affected?• 76510• 76511• 76512• 76513• 76514• 76516• 76519• 92025• 92060• 92081• 92082• 92083• 92132• 92133

• 92134• 92136• 92228• 92235• 92240• 92250• 92265• 92270• 92275• 92283• 92284• 92285• 92286


229

Patient NotificationWHAT IT IS… …AND WHY WE NEED IT


231




54

Patient Notification of Services•Two Types Of Patient Notification•Specific Use For Each•The ABN and NEMB

oABN ‐ Advance Beneficiary Notice “Financial Informed Consent” Patient May Pay Patient Signature Required

oNEMB ‐ Notice Of Exclusion From Medicare Benefits Patient Must Pay – excluded benefits Patient Signature NOT Required


232

Modifiers For Patient Notification•GA – “Waiver of Liability Statement Issued as Required by Payer Policy ”

•GX – “Notice of Liability Issued, Voluntary Under Payer Policy”

•GY – “Statutory exclusions”•GZ – “Expected Denial, No ABN on file”


233

Using The Right Modifier Is Critical• ‐GA indicates that the ABN is required by the payer policy. It is appended to a CPT code to report that a required ABN was issued for a service and is on file. If the service is denied, CMS will assign financial liability to the beneficiary. Because an ABN was properly obtained, the financial liability is legally transferred to the patient and the physician can bill the patient for this service.

• ‐GX When modifier GX is appended to a CPT code, it used to report that a voluntary ABN was issued for a service that is statutorily excluded from Medicare reimbursement. Medicare rejects non‐covered services appended with GX and assigns liability to the beneficiary. Because this is a voluntary ABN, the patient always has financial responsibility for the procedure or test being conducted.


234




55

Using The Right Modifier Is Critical• ‐GZ indicates that a service or item is expected to be denied as unreasonable or unnecessary. It is appended to a CPT code to report that an ABN was not issued for this service. CMS will automatically deny these services and indicate that the beneficiary is not responsible for payment. Because the doctor did not obtain an ABN prior to performing the service, he cannot bill the patient.

• ‐GY When modifier GY is appended to a CPT code to report when a service is specifically excluded by Medicare and an ABN was not issued to the beneficiary. This indicates that the service is statutorily excluded or does not meet the definition of any Medicare benefit. CMS will deny these claims and the beneficiary will be totally responsible for all financial liability.


235

The Interpretation & ReportShould Contain•Indications for testing•Whether the test was ordered•Test reliability•Test results

oComparative findingsoPlan

•Initiation of diagnostic/treatment plan•Doctors signature


237

Clinical Lab Testing In The Optometric Practice


238




56

OK, So What Is CLIA?•Definition:

oClinicalo Labo ImprovementoAmendment(s)•Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed.


239

So, where can you get additional information?

CLIA Defined• A laboratory is any facility that does laboratory testing on specimens derived from humans to give information for the diagnosis, prevention, treatment of disease, or impairment of, or assessment of health.

• CLIA is user fee funded; therefore, regulated facilities cover all the costs of administering the program.

• Centers for Medicare & Medicaid Services (CMS) assumes primary responsibility for financial management operations of the CLIA program.

• The categorization of commercially marketed in vitro diagnostic tests under CLIA is the responsibility of the FDA. This categorization includes the process of assigning commercially marketed in vitro diagnostic test systems to one of three CLIA regulatory categories based on their potential for risk to public health:o waived tests o tests of moderate complexity o tests of high complexity

• CLIA categorizations will also be announced in Federal Register Notices, which will provide opportunity for comment on the decision. FDA may reevaluate and recategorize these tests based upon the comments received in response to the Federal Register Notices.

• FDA will revise as necessary criteria for waivers, moderate and high complexities.


240

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistance/ucm124105.htm ‐ last accessed 11/02/2012

CLIA Waived Tests ‐ Defined• The Law (Public Law 100‐578)• The Clinical Laboratory Improvement Amendments of 1988 (CLIA) law specified that laboratory requirements be based on the complexity of the test performed and established provisions for categorizing a test as waived. Tests may be waived from regulatory oversight if they meet certain requirements established by the statute. The section of the statute specifying the criteria for categorizing a test as waived was excerpted without elaboration in the regulations at 42 CFR 493.15(b) and 493.15(c) contained a list of these waived tests as described below.

• The Regulations (42 CFR part 493)• On February 28, 1992, regulations were published to implement CLIA. In the regulations, waived tests were defined as simple laboratory examinations and procedures that are cleared by the Food and Drug Administration (FDA) for home use; employ methodologies that are so simple and accurate as to render the likelihood of erroneous results negligible; or pose no reasonable risk of harm to the patient if the test is performed incorrectly.


241





57

CLIA Waived Tests ‐ DefinedThe specified tests that are listed in the regulation are:• Dipstick or Tablet reagent urinalysis (non automated) for the following:• Bilirubin • Glucose • Hemoglobin • Ketone • Leukocytes • Nitrite • pH • Protein • Specific gravity • Urobilinogen• Fecal occult blood • Ovulation tests ‐ visual color comparison tests for luteinizing hormone • Urine pregnancy tests ‐ visual color comparison tests • Erythrocyte sedimentation rate‐non‐automated • Hemoglobin‐copper sulfate ‐ non‐automated • Blood glucose by glucose monitoring devices cleared by the FDA specifically for home use • Spun microhematocrit• (added 1/19/93) Hemoglobin by single analyte instruments with self‐contained or component features to

perform specimen/reagent interaction, providing direct measurement and readout


242


CLIA Waived Tests ‐ Defined• In November 1997, the CLIA waiver provisions were revised by Congress to make it clear that tests approved by the FDA for home use automatically qualify for CLIA waiver. Professional use versions of home use tests are not automatically waived. However, such professional versions do qualify for expedited waiver review since only the differences between the home use and professional use versions need to be examined to determine whether the professional version qualifies for waiver.

• To summarize, under the current process, waiver may be granted to:o any test listed in the regulationo any test system for which the manufacturer or producer applies for waiver if that test meets the statutory criteria and the manufacturer provides scientifically valid data verifying that the waiver criteria have been met

o test systems cleared by the FDA for home use.


243


CLIA Waived Tests ‐ Defined• In November 1997, the CLIA waiver provisions were revised by Congress to make it clear that tests approved by the FDA for home use automatically qualify for CLIA waiver. Professional use versions of home use tests are not automatically waived. However, such professional versions do qualify for expedited waiver review since only the differences between the home use and professional use versions need to be examined to determine whether the professional version qualifies for waiver.

• To summarize, under the current process, waiver may be granted to:o any test listed in the regulationo any test system for which the manufacturer or producer applies for waiver if that test meets the statutory criteria and the manufacturer provides scientifically valid data verifying that the waiver criteria have been met

o test systems cleared by the FDA for home use.


244





58

Tearlab•CPT Code

o83861 Description: Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity

• Test both eyes; Code both eyeso83861‐QW‐LT o83861‐QW‐RT (Do NOT use modifier ‐59)

oAdhere to the policy as recommended by your carrier or billing specialist.

o2015 Reimbursement $11.22 per test


245

RPS AdenoPlus™•CPT Code 87809‐QW

oDefinition – Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus

•Claim submissiono87809‐QW‐RTo87809‐QW‐LT

•2015 Reimbursemento$13.15 per test

•Rapid Pathogen Screening Website


246

Let’s Look At More Cases


247




59

Anterior Segment Disorders•Blepharitis•Bacterial/Viral Conjunctivitis•Keratitis


248

Anterior Segment Disorders•Patient Presentation•Patient‐ J.B.

o23 YOWFoVSP InsuranceoBlue Cross

•Chief ComplaintoPatient currently wearing monthly disposable contact lenses Not sure of care products – buys what’s on sale

oO.D. Painful, red, watery, light sensitive, etc…


249

Anterior Segment Disorders•Uncorrected VA’s: O.D. 20/15 O.S. 20/15•Uncorrected Near VA: O.U. J2•Slit lamp shows….


250




60

Anterior Segment – Viral Conjunctivitis (Example)

Diagnosis: 077.8 Other Viral Conjunctivitis

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/24/2015 11 99203 1 $108.39 12 1/24/2015 11 87809-QW-RT 1 $32.64 23456


253

Anterior Segment – Viral Conjunctivitis (Example)

Diagnosis: 077.8 Other Viral Conjunctivitis

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/31/2015 11 99213 1 $72.68 123456


254

Anterior SegmentViral Conjunctivitis (Example)

$213.71© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA





61

MeibomeitisWHEN CLINICAL CARE & MEDICAL CODING COLLIDE


257

Meibomian Gland Dysfunction•1st question to ask is what diagnosis code are you using?

•2nd question to ask is what procedure(s) are you performing?


258

Meibomian Gland Dysfunction•Currently, there is no ICD ‐9 or ICD‐10 code for MGD•Currently, there is no CPT code for either probing or evacuation of the meibomian glands.

•Right now, the only compensation you get is for your office visit and nothing more. So use the appropriate level of 992XX code with a valid ICD‐9 code for current billing procedures. The HCPCS Level III Code 0207T is a tracking code that is to be submitted to the carrier for tracking purposes but is payable by the patient as this is NOT a currently covered procedure.


259




62

What About code 0207T•0207T specifically describes “Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral”, so this code does not cover “probing or manual expression of the glands”.


260

Meibomian Gland Dysfunction•The fact that CMS has issued a tracking code would indicate that they are considering a formal CPT code for this procedure.

•The tracking period is generally 3‐5 years, but never exceeding 5 years.

•That would mean that 2015 – 2016 would be the expected time that there would be reimbursement associated with this procedure.


261

Corneal Abrasion


316




63

Corneal Abrasion•Patient Presentation•Patient‐ P.Q.

o34 YOAMoNo Refractive InsuranceoHigh Deductible Medical Insurance

•Wears daily disposable lenses just for sports & going out•Thinks he scratched his right eye.


317

Corneal Abrasion•Uncorrected VA’s: O.D. 20/25 O.S. 20/20•Uncorrected Near VA: O.U. J2•Refraction: O.D. PLANO –0.50 X177 20/20• O.S. PLANO 20/20•Slit lamp shows typical corneal abrasion with fluorescein


318

So what to do you now?

What Was 92070?•Bandage Contact Lens?•Therapeutic Contact Lens?•Special Type Of Lens Required?


320




64


321

What Was 92070?•Bandage Contact Lens?•Therapeutic Contact Lens?•Special Type Of Lens Required?•92070 – Fitting of a contact lens for medical or therapeutic purposes including supply of lens.

•As of January 1, 2012, 92070 Was No Longer A Valid Code


322

92071 (A Unilateral Code)•CPT Code 92071 – Fitting of a contact lens for treatment of ocular surface disease.

•Please report materials IN ADDITION to this code using either 99070 or the appropriate HCPCS Level II material code.

This is now thought to be appropriatefor a bandage CL situation.

Please do NOT report 92071 and 92072on the same day of service.


323




65

Corneal AbrasionDiagnosis: 918.1, Superficial Injury of Cornea

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



324

The ICD‐10 Era•Procedures

o99203o92071‐RT

•Diagnoses•S05.01XA – Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Initial Encounter

•W22.8XXA – Striking Against or Struck By Other Objects, Initial Encounter


325

Can We Bill For Materials?•We are entitled to bill for materials if we are using a revenue based product, however if we are using a non‐revenue product such as a trial lens (disposable) as our lens there would be no charge.


326




66

Corneal AbrasionTherapeutic Considerations•Cycloplegic•Antibiotic•NSAID•Pressure Patch•Bandage CL•Long Term…

oHyperosmoticso Lubrication therapy


327

Corneal AbrasionDiagnosis: 918.1, Superficial Injury of Cornea

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



328


o99213

•Diagnoses During Follow‐Up VisitsoS05.01XD – Injury of Conjunctiva and Corneal Abrasion Without Foreign Body, Right Eye, Subsequent Encounter

oW22.8XXD – Striking Against or Struck By Other Objects, Initial Encounter


329




67

Corneal Abrasion



Health Care FraudRULES, DAMN RULES, & MORE DAMN RULES


341

Who Is The OIG?THE OFFICE OF INSPECTOR GENERAL


342




68

The OIG & Their Mission•The mission of the Office of Inspector General (OIG), as mandated by Public Law 95‐452 (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs.


343

The OIG & Their Mission•OIG has a responsibility to report both to the Secretary and to the Congress program and management problems and recommendations to correct them. OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission‐related functions performed by OIG components.

http://oig.hhs.gov/


344

The OIG Work Plan• The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging.

• Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

http://oig.hhs.gov/publications/workplan.asp


345




69

Surgical CodesSPECIAL RULES & CIRCUMSTANCES


346

CPT Surgical Package Definition• The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure‐by‐procedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:o Local infiltration, metacarpal/metatarsal/digital block or topical anesthesiao One related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)

o Immediate postoperative care, including dictating operative notes, talking with the family and other physicians

o Writing orderso Typical postoperative follow‐up care


347

One related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)

Global Periods•A Global Period is that period of time for which the follow‐up care related to the surgical procedure, for that specific interval, is compensated for in the “Global” payment for the surgical procedure


348




70

Major vs. Minor Surgery•Minor Surgery

oAny surgical procedure that has a global period of LESS THAN 90 days

•Major SurgeryoAny surgical procedure that has a global period of EQUAL TO or GREATER THAN 90 days


350

Surgical CodingCPT CODE GROUP6XXXX


351

Modifiers Of Special NoteFor Surgical Procedures• ‐24 Unrelated E/M Service, Same Physician, During Post‐Operative Global Period

• ‐25 Separate Service, Same Physician, Same Day• ‐50 Bilateral Procedure• ‐51 Multiple Procedures • ‐54 Surgical Care Only• ‐55 Post‐Operative Care Only• ‐57 Decision To Perform Major Surgery• ‐67 Repeat Procedure or Service, Same Physician• ‐79 Unrelated Procedure, Same Physician, During Post‐Operative Global Period

• ‐RT/LT Right, Left• ‐E1 – E4 Punctal/Lid Identifiers


352




71

Case PresentationsSURGICAL CASES


354

Corneal Foreign Body


355

Corneal Foreign Body•Patient Presentation•Patient‐ N.P.

o33 YOWMoBlue Cross Medical ‐ $2000 DeductibleoPlaying with kid last night in yard “wrestling around” something got in eye, still there, hurts, light sensitive, more in a.m.


356




72

Corneal Foreign Body•Uncorrected VA’s: O.D. 20/30‐ O.S. 20/20•Uncorrected Near VA: O.U. J2•Slit lamp reveals embedded corneal foreign body at 10:00 O.D., etc…


357


358

Why Debride?•Speed/improve healing•Reduce chance of recurrent erosion•Procedure:

o Instill anesthetic antibiotic NSAID

oPull defect toward centeroRoughen basement membrane


359

Photos courtesy of Carl Spear, OD, FAAO




73

Corneal Foreign BodyDiagnosis: 930.00 Corneal Foreign Body, Initial Visit

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/24/2015 11 99203-25 1 $108.39 12 1/24/2015 11 65222 1 $67.36 13 1/24/2015 11 65435 1 $79.87 14 1/24/2015 11 92071 1 $38.17 156


361


o65222o65435

•Diagnoses•T15.01XA – Foreign Body In Cornea, Right Eye, Initial EncounteroZ18.10 – Retained Metal Fragment, UnspecifiedoY93.83 – Activity, Rough Housing And Horseplay


362

Modifier ‐25


363

Significant, Separately Identifiable E/M service

“The patient’s medical record documentation isexpected to clearly evidence that the evaluation andmanagement service performed and billed was “aboveand beyond” the usual pre‐operative and post‐operativecare associated with the procedure performed on thatsame day.”




74

Modifier ‐25The OIG Says...

“We will determine whether providers used modifier –25 appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is unrelated to such procedure or service.”


364

Let’s Look At The Reference

•OIG Publication On NCCI Edits oSpecifically calls out Minor Surgical Procedures


365

Modifier ‐25So What’s Right?•Be sure the record is clear regarding the patient complaint, circumstance, finding, result of diagnostic testing, complication, etc… that supports the need for a SECOND evaluation and management service.

•Reference: CMS Rule


366




75

Corneal Foreign BodyDiagnosis: 930.00 Corneal Foreign Body, Monitoring Visit

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



367


o99213

•DiagnosesoT15.01XD – Foreign Body In Cornea, Right Eye, Subsequent Encounter

oZ18.10 – Retained Metal Fragment, UnspecifiedoY93.83 – Activity, Rough Housing And Horseplay


368

Corneal Foreign BodyDiagnosis: 930.00 Corneal Foreign Body, Monitoring Visit

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



369




76


o99212

•DiagnosesoT15.01XD – Foreign Body In Cornea, Right Eye, Subsequent Encounter

oZ18.10 – Retained Metal Fragment, UnspecifiedoY93.83 – Activity, Rough Housing And Horseplay


370

Corneal Foreign Body



Amniotic MembranesPROKERA® SLIM


372




77

Emerging Paradigm


373

Use PROKERA® SLIM to Prevent Progressive Tissue

Damage

Reduce Inflammation

AND Stimulate Stem Cell

Proliferation

Promote Regenerative Healing

Treat Underlying Pathology

Key to minimizing a sight‐threatening scar is controlling inflammatory response and promoting healing

CPT Definition of 65778 (Chronological)•2011 ‐ Placement of amniotic membrane on the ocular surface for wound healing; self retaining

•2012 ‐ Placement of amniotic membrane on the ocular surface for wound healing; self retaining

•2013 – Placement of amniotic membrane on the ocular surface for wound healing; self retaining

•2014 – Placement of amniotic membrane on the ocular surface; without sutures


374

Coding For 65778•V2790 (amniotic membrane for surgical reconstruction, per procedure) cannot be billed on same day as 65778 as it is already included in the reimbursement for the surgical code it self for CMS.


375




78

PROKERA® Commonly Used ICD‐9 Codes


376

ICD‐9 To ICD‐10ICD‐9

•370.35 (Neurotrophic Keratoconj)•370.00 (Corneal Ulcer, unspecified)•370.33 (KCS, not Sjogren’s)•370.21 (Punctate Keratitis)•054.42 (Dendritic Keratitis)

ICD‐10

•H16.23 (1,2,3,9)•H16.00 (1,2,3,9)•H16.22 (1,2,3,9)•H16.14 (1,2,3,9)•B00.52


377

Handling Claim Rejections•First rule – understand what was rejected and why

oScope of practice (provider type)o Improper code submission With office visit With V2790 Location indicator should be “11” (outpatient – office location)

•Once you understand why the claim was rejected, it is much easier to guide the physician to get reimbursed by properly resubmitting the claim.


378




79

CPT Code 65778 – Things To NoteCPT CHARACTERISTICS

• Active CMS Code With Reimbursement

• Bilateral 150% Procedure• Total Non‐Facility RVU Value = 38.77• Global Period = 10 Days• National Average CMS Reimbursement is $1,389.95

• LCD’s Generally Don’t Cover 65778• Include Statement Of Medical Necessity & Surgical Report

MINOR SURGICAL PROCEDURE RULES

• Office Visit Related To The Decision To Perform Surgery Is Already Included In Reimbursement For 65778

• Use of Modifier ‐25 Should Be Rare• Cannot Bill Materials In Addition To Surgical Code

• V2790 Is NOT Billed In Addition To 65778 For CMS, Although Some Other Third Party Carriers May Allow


379

RecurrentCorneal Erosion


380

Recurrent Corneal Erosion•Patient Presentation•Patient‐W.A

o67 YOWMoMedicare•Chief Complaint – Left Eye

oRecurrent episodes of ocular painoForeign body sensationoPhotophobiaoDecreased visionoWatering upon awakening


381




80

Clinical Presentation•Reduced vision (hazy)•Positive staining•Hard to hold eye open•Epithelial disruption•No folds in Descemet’s membrane

•Initial Treatment Protocolo Cycloplegiao NSAIDo BCL?

© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA DUPLICATION PROHIBITED WITHOUT PERMISSION. ALL RIGHTS RESERVED. 382

Recurrent Corneal Erosion


383

Diagnosis: 371.42, Recurrent Erosion Of Cornea

Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY


1 1/23/2015 11 99213 1 $72.68 12 1/23/2015 11 92071-LT 1 $38.17 13456

The ICD‐10 Era•ICD‐9

o371.42 Recurrent Erosion Of Cornea

•ICD‐10oH18.832 – Recurrent Erosion Of Cornea, Left Eye


384




81

Recurrent Corneal Erosion


385


Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY


1 1/30/2015 11 99213 1 $72.68 12 1/30/2015 11 65600 1 $396.99 13 1/30/2015 11 65435 1 $79.87 1456

Recurrent Corneal Erosion ‐ PROKERA®


386


Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY


1 2/15/2015 11 65778-LT 1 $1,391.27 123456

RecurrentCorneal ErosionWITH PROKERA (CMS)

$1,838.07© 2008 ‐ 2015 PRACTICE RESOURCE MANAGEMENT, INC. – J. RUMPAKIS, OD, MBA





82

Glaucoma


395

Glaucoma•Patient Presentation•Patient‐ Q.C.

o45 YOBMoVSP InsuranceoBlue Cross Medical

•1st eye exam ever•Chief Complaint

oHaving a very difficult time reading


396

Glaucoma•Uncorrected VA’s: O.D. 20/25 O.S. 20/20•Uncorrected Near VA: O.U. J5•FDT Testing‐ Normal•NCT @ 8:15 a.m.: O.D. 23 O.S. 22•Refraction: O.D. PLANO – 0.50 X87 20/20• O.S. PLANO 20/20•Near Add: +1.50 20/20 @ 40cm.


397




83

Glaucoma•Goldmann @ 8:45 a.m., O.D. 22 O.S. 22•DFE with 2.5% Phenylepherine, 1% Tropicamide•Retinal evaluation with 78D lens•O.D. C/D .6 x .6 O.S. .7 x .7•Deep cylindrical cupping•Goldmann @ 9:25 a.m., O.D. 20 O.S. 20


398

What Do You Do?•Complete the comprehensive exam•Closing conference with patient•Educate regarding glaucoma

oSeveral different types / basic examplesoNeed to confirm and differentiateoAdditional testing (scheduling)

•Bill VSP for exam & optical


399

Coding The Initial EncounterDiagnosis: 365.05, Open Angle Glaucoma - Borderline Findings - High Risk

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier1 1/17/2015 11 92004 1 $148.83 12 1/17/2015 11 92015 2 $19.93 13456


400




84

Now What Do You Do?•Schedule additional testing (Week 1)

oVisual FieldsoGonioscopyoFundus PhotographyoPachymetry


401

Coding The Second EncounterDiagnosis: 365.05, Open Angle Glaucoma - Borderline Findings - High Risk

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier1 1/24/2015 11 99214 1 $107.90 12 1/24/2015 11 92250 1 $79.29 13 1/24/2015 11 92020 1 $26.77 14 1/24/2015 11 92083 1 $64.63 15 1/24/2015 11 76514 1 $15.29 16


402

Now What Do You Do?•Schedule additional testing (Week 2)

oSerial TonometryoAnalysis of Nerve Fiber Layer


403




85

Coding The Third EncounterDiagnosis: 365.05, Open Angle Glaucoma - Borderline Findings - High Risk

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier1 1/31/2015 11 99213 1 $72.68 12 1/31/2015 11 92133 1 $45.32 13 1/31/2015 11 92100 1 $80.72 14 156


404

Why Can’t I Just DoWhat I Want?THE NATIONAL CORRECT CODING INITIATIVE


405

NCCI Edits•National Correct Coding Initiative

oThese edits are updated quarterly

•Developed by:oCPT®oNational & Local Policy EditsoNational Societies GuidelinesoStandard Medical & Surgical Practices


406




86

Format of the CCI Edits•Two different types of edits:•Column 1/Column 2 Edits (formerly Comprehensive/Component Edits)

•Mutually Exclusive Edits


407

Column 1/Column 2 Edits•The Column 2 code will not be paid when it is rendered by the same provider on the same date of service because it is considered to be part of the comprehensive codeoExample 92083/99211 92004/92020

•Unless a modifier is used citing special circumstances


408

Mutually Exclusive•Procedures defined as those which cannot be reasonably performed by a physician in the same patient encounter.

o92004/92002o68801/68761o92250/92133


409




87

Case Example•Going back to our Glaucoma case…

o I do it all of the time…o I have never gotten in trouble…

•“Dr. Rumpakis, you must not know about certain modifiers that we use to get around the rules…”


410

Modifier ‐59Distinct Procedural Service•Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.

•Modifier –59 is used to identify procedure(s) & service(s) that are not normally reported together, but are appropriate under the circumstances.o This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician.


411

Modifier ‐59Distinct Procedural Service• Modifier 59 will only be recognized as valid to bypass edits when:

• Combination of procedure codes represent procedures that would not normally be performed at the same time (e.g. procedure on head and procedure on feet; craniotomy and setting of compound fracture)

• Different session or patient encounter is documented in patient’s medical record

• Surgical procedures performed are not through the same incisional site (Note: doesn’t matter if instrumentation changes if incision or presentation is the same)

• Surgical knee procedures involving multiple compartments of the same knee

• Another modifier is not more appropriate (e.g. Modifier 51)• Used as a modifier of last resort


412




88

Modifier ‐59 & The “X Codes”•Perspective: Modifier 59 is the most widely used HCPCS modifier: It is defined for use in a wide variety of circumstances, and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. This modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of modifier 59 and help to improve claims processing for providers.


413

Modifier ‐59 & The “X Codes”•The Centers for Medicare & Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the ‐59 modifier, which is used to designate a “distinct procedural service.”

•The implementation date for this change is Jan. 5, 2015. Initially, either modifier 59 or a more selective –X{EPSU} modifier will be accepted, although CMS has encouraged a rapid migration of providers to the more selective modifiers. For further instructions regarding this change check with your MAC.


414

Modifier ‐59 & The “X Codes”• Transmittal 1422, Change Request 8863 provides that CMS is establishing the following new modifiers—referred to collectively as ‐X{EPSU} modifiers—to define specific subsets of the ‐59 modifier:

• XE ‐ Separate Encounter: A service that is distinct because it occurred during a separate encounter

• XS ‐ Separate Structure: A service that is distinct because it was performed on a separate organ/structure

• XP ‐ Separate Practitioner: A service that is distinct because it was performed by a different practitioner

• XU ‐ Unusual Non‐Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service


415




89

Modifier ‐59 & The “X Codes”•Although CMS will continue to recognize modifier 59 in many instances, per CR8863:

•CPT instructions state that the ‐59 modifier should not be used when a more descriptive modifier is available. CMS may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. o For example, a particular NCCI PTP code pair may be identified as payable only with the ‐XE separate encounter modifier but not the ‐59 or other ‐X{EPSU} modifiers.

o The ‐X{EPSU} modifiers are more selective versions of the ‐59 modifier so it would be incorrect to include both modifiers on the same line.


416

Bypassing The RulesWHEN IS IT LEGIT?.. .


417

Now What Do You Do?•Confirm Dx with patient•Confirm need for treatment and consequences of not treating

•Select medication and explain your choice•Review the use of medication•Sample•Schedule to monitor in 1 week


418




90

Now What Do You Do?•Tonometry at next visit•Educate patient as to reduction of IOP•Confirm diagnosis•Write prescription•Schedule for 3 week monitoring


419

Coding The Fourth EncounterDiagnosis: 365.11, Primary Open Angle Glaucoma & 365.71, Mild Stage Glaucoma

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier1 2/23/2015 11 99213 1 $72.68 123456


420

Now What Do You Do?•Educate patient as to reduction and stability of IOP •Schedule for 3 month monitoring

oSerial Tonometry


421




91

Coding The Fifth Encounter

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YY To MM/DD/YY CPT-HCPCS - Modifier1 5/23/2015 11 99213 1 $72.68 12 5/23/2015 11 92100 1 $80.72 13456

Diagnosis: 365.11, Primary Open Angle Glaucoma & 365.71, Mild Stage Glaucoma


422

Now What Do You Do?•Educate stability of IOP •Schedule for 3 month monitoring


423

Now What Do You Do?•Tonometry (7 months)•Educate stability of IOP •Schedule for 3 month monitoring


424




92

Coding The Sixth Encounter

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom




425

Now What Do You Do?•Tonometry (10 months)•Educate stability of IOP •Schedule for 3 month monitoring


426

Coding The Seventh Encounter


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom



427




93

Summary Of Care Year One•Comprehensive exam•1 Primary Diagnostic Visit•1 Secondary Diagnostic Visit•4 Monitoring Visits


428

Summary Of FeesYEAR ONE


429

Fee Summary – Year One


430

Date Of Service Total Fees Per Visit1/17/2015 $168.761/24/2015 $293.881/31/2015 $198.722/23/2015 $72.685/23/2015 $153.408/23/2015 $72.6811/23/2015 $72.68

$887.44$960.12

$1,032.80

Running Total For Care Provided$168.76$462.64$661.36$734.04

Medicare




94

Care For Year 2 & Beyond


431

Procedure Fees Per Procedure92014 $123.8592015 $19.9399213 $72.6892083 $64.6392250 $79.2992100 $80.7292020 $26.7799213 $72.6892133 $45.32

Running Total For Care Provided

$441.10

$123.85$143.78$216.46

$540.55$585.87

$281.09$360.38

$467.87

Medicare

Fee Summary – Year One


432

1/17/2015 $298.021/24/2015 $518.971/31/2015 $350.932/23/2015 $128.355/23/2015 $270.898/23/2015 $128.3511/23/2015 $128.35

$298.02$816.99

$1,167.92$1,296.26$1,567.16$1,695.51$1,823.85

Typical Non-Medicare Carrier

Care For Year 2 & Beyond


433

92014 $218.7192015 $19.9399213 $128.3592083 $114.1392250 $140.0292100 $142.5592020 $47.2799213 $128.3592133 $80.03

$218.71$238.64$366.99$481.12

$1,019.34

$621.14$763.69$810.96$939.31

Typical Non-Medicare Carrier




95

How Would You Handle This Situation?•Patient calls for an eye exam•Patient is on the books for an eye exam•Patient presents with this statement

o “I’m here today because I have a family history of glaucoma and I want to get checked to see if I have it.”

•No refractive insurance, but has medical insurance – no deductible, $25 co‐pay

•How would you handle this?


434

Special GlaucomaService Codes – The G Codes• The “G” Codes

o G0117, reported when performed only by an optometrist or ophthalmologisto G0118, reported when performed under the direct supervision of an optometrist or ophthalmologist

o Diagnosis code of V80.1 should be used

• Codes are to be used when the glaucoma screening is the only service provided or when it is provided as part of an otherwise non‐Medicare covered service

•Only high‐risk patients are eligible for this benefit:o those with a family history of glaucomao those with diabetes mellituso African‐Americans over age 50o Hispanics over age 65 (Added In 2006)


435

Special GlaucomaService Codes – The G Codes•Includes:

oVisual Acuitieso IOP measurementoDilated exam, direct or slit lamp ophthalmoscopy


436




96

DiabetesA VERY SPECIAL CASE IN OPHTHALMIC PRACTICES


467

Diabetic Retinopathy•Patient Presentation•Patient‐ D.B.

o55 YOWMoVSP InsuranceoBlue Cross Medical

•Chief ComplaintoPCP just told him that he has just “a little” diabetes and should get his eyes checked.


468

Coding Concepts

•Medical vs Refractive


•Chief Complaint


Diabetic Retinopathy•Uncorrected VA’s: O.D. 20/25 O.S. 20/20•Uncorrected Near VA: O.U. J5•Refraction: O.D. +0.25 –0.50 X 115 20/20• O.S. +0.50 SPH 20/20•Near Add: +2.50 20/20


469




97

Diabetic Retinopathy•Goldmann @ 3:45 p.m., O.D. 17 O.S. 15•Fundus exam through dilated pupil•Retinal findings consistent with Grade 1 background diabetic retinopathy


470

Non ProliferativeDiabetic Retinopathy ‐ BackgroundDiagnosis: 362.01, 250.5X, Non Proliferative Diabetic Retinopathy, Diabetes w/Ophthalmic Manifestations

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



471


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/31/2015 11 99213 1 $72.68 12 1/31/2015 11 92250 1 $79.29 13 1/31/2015 11 92083 1 $64.63 1456


472




98


Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY


1 2/6/2015 11 99213 1 $72.68 12 2/6/2015 11 92134 1 $45.32 13456


473


Dates of Service

Place of Service

Type of Service



Days or

Units

From MM/DD/YY


1 3/6/2015 11 99213 1 $72.68 123456


474


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



475




99


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



476

Non ProliferativeDiabetic Retinopathy ‐Background



Diabetic ICD‐9 Coding Rules•Must always indicate “Dual‐Diagnosis” if indicating diabetic retinopathyoAssignment of diabetes – 250.5XoSpecific type of diabetic retinopathyoCode set expanded in 2005 362.04 Mild Non‐Proliferative 362.05 Moderate Non‐Proliferative 362.06 Severe Non‐Proliferative 362.07 Diabetic Macular Edema 362.03 NOS (Not Otherwise Specified)


478




100

Choroidal Nevus(BENIGN NEOPLASM)


479

Choroidal Nevus•Patient Presentation•Patient‐ L.B.

o38 YOAFoVSPoAetna for medical

•Routine Exam – no problems, annual examination by recall


480

Coding Concepts

•New vs Established

•Medical vs Refractive


•Chief Complaint


Choroidal Nevus•Uncorrected VA’s: O.D. 20/20 O.S. 20/20•Uncorrected Near VA: O.U. 20/20•Refraction: O.D. +0.25 – 0.25 X 006 20/20• O.S. +1.00 – 0.50 X 178 20/20


481




101

Choroidal Nevus•Goldmann @ 11:45 a.m., O.D. 15 O.S. 15•O.D. C/D .2 x .2 O.S. .2 x .3•Direct ophthalmoscopy reveals suspect “Nevus” in right eye

•Patient rescheduled for follow‐up


482

Choroidal NevusDiagnosis: 224.6 Benign Neoplasm, Choroid

Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



483


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 1/31/2015 11 99213 1 $72.68 12 1/31/2015 11 92250 1 $79.29 13 1/31/2015 11 92083 1 $64.63 1456


484




102


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo

MM/DD/YY CPT-HCPCS - Modifier1 2/6/2015 11 99213 1 $72.68 12 2/6/2015 11 92134 1 $45.32 13 1456


485


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



486


Dates of Service

Place of Service

Type of Service



Days or

UnitsFrom

MM/DD/YYTo



487




103

My Action PlanWHAT DO I DO NOW?...


533

“Intent” vs. “Impact”


534

We ALL have great intentions!There is often a clear difference that occurs between what you had intended to do and

what you actually did

Just Do It vs. Just Think About It

The Power Of I to the 4th Power


535

Integrate Implement

Intent Impact




104

John’s 12‐Step ProgramHI, MY NAME IS <BLANK…>I AM A REFORMED CODER…


538

John’s 12‐Step Program•Identify carriers with whom you want to be on their plan –it’s a business decision!

•Establish “Needs Assessment” for your situation Obtain resource material that you need

•Create disease protocols for your office Review the findings regarding the health and vision of each patient Correspond with the patients PCP regarding your care and the patients condition Develop system for appointing the patients next visit before they leave the office Put the process in flow chart format


539

John’s 12‐Step Program•Everyone in the office must be educated about the protocol and the processoAll staff must be onboard with providing the highest level of care

◦ Diagnosis◦ Treatment◦ Selection of Medication

•Market your ability to provide primary care to your patient base Set Goals, Objectives, Strategies, and Tactics for what you want to achieve


540




105

John’s 12‐Step Program•Always perform the standard of care as your baseline•Document the medical record with your thoughts and impressions

•Be vigilant about proper coding Perform internal audits on a regular basis Use a grading sheet on a regular basis Keep up with change in coding protocols Develop office strategy for change mgmt


541

John’s 12‐Step Program•Develop office strategy for change management Rules & requirements change frequently

•Be audit proof – a perfect medical record that accurately reflects the care provided and outcomes attained is priceless

•Never be complacent!•Keep up on your continuing education and remember that your medical record and subsequent coding of your services is a legal requirement – it’s not an option!


542


543

Cracking The Code

Clinical Case Management &Medical Record ComplianceSCO – Destination CE 2015 John Rumpakis, OD, MBA

Practice Resource Management, Inc.

Cracking The Code - Texas Optometric Associationtexas.aoa.org/Documents/TX/2015 Convention/OD...

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Transcript of Cracking The Code - Texas Optometric Associationtexas.aoa.org/Documents/TX/2015 Convention/OD...