Welcome to CODEquest 2008!. Congratulations to all who have passed the Ophthalmic Coding Specialist...

Welcome to Welcome to

CODECODEquestquest 2008! 2008!

Congratulations Congratulations

to all who have passed the to all who have passed the

Ophthalmic Coding Specialist ExamOphthalmic Coding Specialist Exam

CODEquest – Financial DisclosureCODEquest – Financial Disclosure

Ms. VicchrilliMs. Vicchrilli

does not have any financial interest or does not have any financial interest or relationships to disclose.relationships to disclose.

CODEquest TopicsCODEquest Topics

In the following patient examples, we In the following patient examples, we will cover:will cover:

• E&M vs. Eye codesE&M vs. Eye codes

• ConsultationsConsultations

• Special testingSpecial testing


• Modifier applicationModifier application

• Minor procedures for each specialtyMinor procedures for each specialty

• Major surgical procedures for each Major surgical procedures for each specialty; andspecialty; and


• Answer the really tough questions.Answer the really tough questions.


• Billing for the interim exam between Billing for the interim exam between cataract surgeriescataract surgeries

• Billing for an injection and an exam the Billing for an injection and an exam the same daysame day

• Billing for OCT and fundus Billing for OCT and fundus photography on the same dayphotography on the same day


• Coding for new corneal proceduresCoding for new corneal procedures


• There will also be staff meetings.There will also be staff meetings.

AgendaAgenda

1.1. What’s new in 2008What’s new in 2008

2.2. EthicsEthics

3.3. EOMB errorsEOMB errors


• Tips from the most effective offices.Tips from the most effective offices.

What’s New in 2008What’s New in 2008

• Medicare Part B deductible increases Medicare Part B deductible increases to to $135$135 compared to $131 in 2007. compared to $131 in 2007.

2008 CPT Update2008 CPT Update

InitialInitial Nursing Facility Care Nursing Facility Care

Change of descriptionChange of description

99304 99304 Physicians typically spend 25 minutes Physicians typically spend 25 minutes with the patient and/or family or caregiverwith the patient and/or family or caregiver

99305 99305 35 minutes35 minutes

9930699306 45 minutes 45 minutes


Subsequent Nursing Facility CareSubsequent Nursing Facility Care


9930799307 Physicians typically spend 10 minutes with the patient and/or family or Physicians typically spend 10 minutes with the patient and/or family or caregiver.caregiver.





• CPT code 67038 Vitrectomy, mechanical, pars plana approach; with CPT code 67038 Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping epiretinal membrane stripping

– – will be will be deleteddeleted and replaced with three new codes and replaced with three new codes


67041 Vitrectomy, mechanical, pars plana approach; 67041 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, with removal of preretinal cellular membrane (eg, macular pucker)macular pucker)

6704167041

CCI edits:CCI edits:

36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 65800, 65805, 65810, 65815, 66830, 66840, 66852, 66920, 66930, 64475, 65800, 65805, 65810, 65815, 66830, 66840, 66852, 66920, 66930, 66940, 67005, 67010, 67015, 67025, 67027, 67028, 67036, 67101, 67105. 66940, 67005, 67010, 67015, 67025, 67027, 67028, 67036, 67101, 67105. 67107, 67110, 67112, 67120, 67121, 67141, 67145, 67500, 67515, 68200, 67107, 67110, 67112, 67120, 67121, 67141, 67145, 67500, 67515, 68200, 90760, 90765, 90772, 90774, 90775. Mutually exclusive 6999090760, 90765, 90772, 90774, 90775. Mutually exclusive 69990

6704167041

RVUs: 30.23 no site-of-service differentialRVUs: 30.23 no site-of-service differential

Global period: 90 daysGlobal period: 90 days

Assistant-at-surgery: yes Assistant-at-surgery: yes


67042 with removal of internal limiting membrane of retina (eg, 67042 with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil)performed, intraocular tamponade (ie, air, gas or silicone oil)

6704267042


36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 67036, 67108, 67110, 67112, 67500, 90760, 90765, 90772, 90774, 67036, 67108, 67110, 67112, 67500, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 90775. Mutually Exclusive 69990

6704267042

RVUs: 34.62 no site-of-service differentialRVUs: 34.62 no site-of-service differential




67043 with removal of subretinal membrane (eg, choroidal neovascularization), includes, if 67043 with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulationperformed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation

6704367043


36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 64470, 64475, 66830, 66840, 66852, 66920, 66930, 66940, 67025, 67036, 67107, 67108, 67110, 67112, 67113, 67500, 90760, 90765, 67036, 67107, 67108, 67110, 67112, 67113, 67500, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 90772, 90774, 90775. Mutually Exclusive 69990

6704367043

RVUs: 36.33RVUs: 36.33




67113 Repair complex retinal detachment (eg, proliferative 67113 Repair complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser phtoocoagulation, or silicone oil tamponade, cryotherapy, endolaser phtoocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens drainage of subretinal fluid, scleral buckling, and/or removal of lens

6711367113


G0186, 36000, 36410, 37202, 62318, 62319, 64400, 64402, 64405, 64415, 64416, G0186, 36000, 36410, 37202, 62318, 62319, 64400, 64402, 64405, 64415, 64416, 64417, 64450, 64470, 64475, 66830, 66840, 66850, 66852, 66920, 66930, 66940, 64417, 64450, 64470, 64475, 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66985, 66986, 67005, 67010, 67015, 67025, 67028, 67030, 66982, 66983, 66984, 66985, 66986, 67005, 67010, 67015, 67025, 67028, 67030, 67031, 67036, 67039, 67040, 67041, 67042, 67101, 67105, 67107, 67108, 67110, 67031, 67036, 67039, 67040, 67041, 67042, 67101, 67105, 67107, 67108, 67110, 67112, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 67500, 67112, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 67500, 67515, 68200, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 67515, 68200, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990

6711367113

RVUs: 39.88RVUs: 39.88

Global period: 90 dayGlobal period: 90 day



67229 Treatment of extensive or progressive 67229 Treatment of extensive or progressive retinopathy, one or more sessions; preterm infant retinopathy, one or more sessions; preterm infant (less than 37 weeks gestation at birth), performed (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathyof from birth up to 1 year of age (eg, retinopathyof prematurity), photocoagulation or cryotherapyprematurity), photocoagulation or cryotherapy

6722967229


36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 67500, 67515, 90760, 90765, 90772, 64450, 64470, 64475, 67500, 67515, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 90774, 90775. Mutually Exclusive 69990

6722967229

RVUs: 26.23RVUs: 26.23


Assistant-at-surgery: no Assistant-at-surgery: no

CPT UpdateCPT Update

Change of description - ?Change of description - ?

67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions, cryotherapy, 67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions, cryotherapy, diathermydiathermy

Old languageOld language

67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions;; cryotherapy, cryotherapy, diathermydiathermy



67228 Treatment of extensive or progressive retinopathy, one or more sessions; (eg, diabetic retinopathy), photocoagulation67228 Treatment of extensive or progressive retinopathy, one or more sessions; (eg, diabetic retinopathy), photocoagulation

Old languageOld language

Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; photocoagulation (laser or Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc)xenon arc)


• 68816 Probing of nasolacrimal duct, with or without irrigation; 68816 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilationwith transluminal balloon catheter dilation

6881668816


36000, 36410, 67202, 62318, 62319, 64415, 64416, 64417, 36000, 36410, 67202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 67500, 68810, 68811, 90760, 90765, 64450, 64470, 64475, 67500, 68810, 68811, 90760, 90765, 90772, 90774, 90775. Mutually Exclusive 69990 90772, 90774, 90775. Mutually Exclusive 69990

6881668816

RVUs: 15.91/5.67RVUs: 15.91/5.67


Assistant-at-surgery: no Assistant-at-surgery: no



92135 Scanning computerized ophthalmic diagnostic imaging, 92135 Scanning computerized ophthalmic diagnostic imaging, posterior segmentposterior segment, (eg, scanning , (eg, scanning laser) with interpretation and report, unilaterallaser) with interpretation and report, unilateral


Category III code:Category III code:

0187T Scanning computerized ophthalmic diagnostic imaging, 0187T Scanning computerized ophthalmic diagnostic imaging, anterior segmentanterior segment, with interpretation and , with interpretation and report, unilateralreport, unilateral

No RVUs – until a local policy developed, patient is responsible for paymentNo RVUs – until a local policy developed, patient is responsible for payment

New PhotoScreening CodeNew PhotoScreening Code

• 9917499174 Ocular photoscreening with Ocular photoscreening with interpretation and report, bilateralinterpretation and report, bilateral

– (Do not report 99174 in conjunction with (Do not report 99174 in conjunction with 92002-92014, 99172, 99173)92002-92014, 99172, 99173)

• Deleted 0065T to create new Category 1 Deleted 0065T to create new Category 1 code for photoscreening code for photoscreening

• Not valued by the RUCNot valued by the RUC

HCPCS UpdateHCPCS Update

• Lucentis received a HCPCS code November 5Lucentis received a HCPCS code November 5thth - -

• J2778, ranibizumab injection 0.1mg effective January 1, J2778, ranibizumab injection 0.1mg effective January 1, 2008. Put 5 in the unit field2008. Put 5 in the unit field

ASC UpdateASC Update

• Effective January 1, 2008 all surgical procedures will be Effective January 1, 2008 all surgical procedures will be ASC approved, with the exception ofASC approved, with the exception of

- codes that contain the description of “with hospitalization”- codes that contain the description of “with hospitalization”

- procedures that require an over-night hospital stay - procedures that require an over-night hospital stay

Office of the Inspector GeneralOffice of the Inspector General

• To promote integrity, economy, efficiency and To promote integrity, economy, efficiency and effectiveness within all HHS programseffectiveness within all HHS programs

• Chief audit and law enforcement executive for the Chief audit and law enforcement executive for the entire Department, including the Centers for entire Department, including the Centers for Medicare & Medicaid Services. Medicare & Medicaid Services.

2008 OIG Work Plan2008 OIG Work Plan

• Place of Service ErrorsPlace of Service Errors– Because different settings pay at different rates OIG Because different settings pay at different rates OIG

wants to ensure accurate reporting of setting wants to ensure accurate reporting of setting

• E&M Services During Global Surgery PeriodsE&M Services During Global Surgery Periods– Investigation as to the number of E&M services Investigation as to the number of E&M services

provided by physicians and reimbursed as part of the provided by physicians and reimbursed as part of the global surgery feeglobal surgery fee

2008 OIG Work Plan2008 OIG Work Plan

• Medicare Payments for Selected Physician Medicare Payments for Selected Physician ServicesServices

– Very few details except that they will review Very few details except that they will review appropriateness of billing for physician servicesappropriateness of billing for physician services

• Medicare “incident-to” ServicesMedicare “incident-to” Services– Will review medical necessity, quality of care and Will review medical necessity, quality of care and

documentation for these services documentation for these services

2008 OIG Work Plan2008 OIG Work Plan• Assignment Rules by Medicare ProvidersAssignment Rules by Medicare Providers

– Providers can’t balance bill beneficiaries for amounts Providers can’t balance bill beneficiaries for amounts in excess of the Medicare allowable in excess of the Medicare allowable

• Geographic Areas with High Utilization of Geographic Areas with High Utilization of Ultrasound ServicesUltrasound Services

– Examine disproportionately high Medicare allowed Examine disproportionately high Medicare allowed charges and services per beneficiary --charges and services per beneficiary --codes affecting ophthalmology are:codes affecting ophthalmology are:

– 76510, 76511, 76512, 76513, 76514, 76516, 76519, 76510, 76511, 76512, 76513, 76514, 76516, 76519, 76529 76529

Questions?Questions?

CIGNA LCDsCIGNA LCDs

BlepharoplastyBlepharoplasty December 2005December 2005

Botulinum ToxinBotulinum Toxin January 2007January 2007

Cataract Extraction Cataract Extraction Preoperative EvaluationPreoperative Evaluation

November 2004November 2004

Computer Corneal Computer Corneal TopographyTopography

November 2006November 2006

Extended OphthalmoscopyExtended Ophthalmoscopy July 2007July 2007

Fundus PhotographyFundus Photography November 2007November 2007

CIGNA LCDsCIGNA LCDs

General Ophthalmological General Ophthalmological ServicesServices

September 2007September 2007

Removal Benign Skin LesionRemoval Benign Skin Lesion November 2007November 2007

SLGTSLGT November 2007November 2007

Visual FieldVisual Field November 2007November 2007

YAGYAG May 2007May 2007

• When you accept payment from a When you accept payment from a third party payer, each will have its third party payer, each will have its own policies to follow:own policies to follow:

- Medicare- Medicare

- Non-Medicare or commercial payers- Non-Medicare or commercial payers

- Medicaid- Medicaid

E&M vs. Eye CodesE&M vs. Eye Codes

- Review requirements for E&M- Review requirements for E&M

- Review requirements for Eye codes- Review requirements for Eye codes

E&M vs. Eye CodesE&M vs. Eye Codes

9920199201 1.031.03 9924199241 1.351.35

9920299202 1.771.77 9200292002 1.831.83 9924299242 2.522.52

9920399203 2.542.54 9924399243 3.463.46

9920499204 3.913.91 9200492004 3.433.43 9924499244 5.115.11

9920599205 4.944.94 9924599245 6.246.24

E&M vs. Eye codesE&M vs. Eye codes9921199211 0.50.5

9921299212 1.031.03 9201292012 1.931.93

9921399213 1.711.71

9921499214 2.572.57 9201492014 2.822.82

9921599215 3.463.46

• The first several patients of the day The first several patients of the day are established patientsare established patients

Patient #1Patient #1

• Patient c/o bumps Patient c/o bumps RUL, causing RUL, causing significant significant swelling x 2 days. swelling x 2 days. Slight discharge Slight discharge in am. Blurred in am. Blurred vision. Warm vision. Warm compresses some compresses some helphelp

Chief Chief complaintcomplaint

BumpsBumps

LocationLocation Right upper Right upper lidlid

QualityQuality SignificantSignificantDurationDuration 2 days2 days

Associated Associated signssigns

Blurred Blurred visionvision

Modifying Modifying factorsfactors

Warm Warm compresses compresses helphelp


• Diagnosis chalazion (plural = chalazia) Diagnosis chalazion (plural = chalazia) 373.2373.2

• Excision is performed Excision is performed

Patient #1 – Coding OptionsPatient #1 – Coding Options

6780067800 Excision chalazion; singleExcision chalazion; single Put 2 in the unit Put 2 in the unit fieldfield

6780067800 Excision chalazion; singleExcision chalazion; single Append modifier Append modifier 59 indicting two 59 indicting two separate sitesseparate sites

6780167801 Excision chalazion; Excision chalazion; multiple, same lidmultiple, same lid

E3 or no modifierE3 or no modifier

Patient #1Patient #19921299212 Established patient Established patient

level 2level 2-25-25 $38$38

6780167801 Excision of chalazion; Excision of chalazion; multiple, same lidmultiple, same lid

No modifierNo modifier $146$146


• Note:Note: Some non-Medicare payers Some non-Medicare payers always bundled the exam with a minor always bundled the exam with a minor procedure performed on the same day.procedure performed on the same day.


• CC: FB sensation CC: FB sensation OS x early this OS x early this am. +3 pain, am. +3 pain, photophobia. Pt photophobia. Pt building tool shedbuilding tool shed


Foreign bodyForeign body

LocationLocation Left eyeLeft eye

QualityQuality +4 pain+4 painDurationDuration Early Early

morningmorningAssociated Associated signssigns

PhotophobiaPhotophobia


Working Working with with wood/metalwood/metal


• Diagnosis 930.8 Foreign bodyDiagnosis 930.8 Foreign body

• Removal is performedRemoval is performed


9921399213 Established patient Established patient level 3; orlevel 3; or

-25-25 $62$62

9201292012 Intermediate examIntermediate exam -25-25 $64$64

6522265222 Removal of foreign Removal of foreign body, external eye; body, external eye; corneal, with slit lampcorneal, with slit lamp

-LT-LT $69$69


• P/O cataract OS x three weeksP/O cataract OS x three weeks

C/O decreased visionC/O decreased vision

DX Cystoid macular edemaDX Cystoid macular edema


• Is this a billable exam?Is this a billable exam?

• If referred to a retina specialist – is it a If referred to a retina specialist – is it a billable exam?billable exam?

- within the practice?- within the practice?

- outside the practice?- outside the practice?


• P/O cataract OD 1 month. Vision not P/O cataract OD 1 month. Vision not as good as it was previously. Presents as good as it was previously. Presents today for glaucoma check OStoday for glaucoma check OS

• Exam revealed capsular haze OD, IOP Exam revealed capsular haze OD, IOP check OS, YAG performed ODcheck OS, YAG performed OD


• Is this a billable visit? Is this a billable visit?

• Is documentation sufficient?Is documentation sufficient?

• What modifiers should be appended?What modifiers should be appended?


• Exam modifiers 24 and 57Exam modifiers 24 and 57

• YAG modifier RTYAG modifier RT


• CC: Progressive CC: Progressive decreased vision decreased vision OU x 3 months. OU x 3 months. OD worse. OD worse. Difficulty Difficulty performing any performing any near work, near work, sewing, reading sewing, reading


Decreased Decreased visionvision

LocationLocation Both eyesBoth eyes

QualityQuality ProgressiveProgressiveDurationDuration Three monthsThree months


Right eye Right eye worseworse


Problems Problems seeing at nearseeing at near


• Exam reveals bilateral cataracts. Exam reveals bilateral cataracts. IOLMaster is orderedIOLMaster is ordered

• Surgery scheduled for the right eyeSurgery scheduled for the right eye

• Patient requests P-C IOL. NEMB is Patient requests P-C IOL. NEMB is signed and specialized informed signed and specialized informed consent givenconsent given


9920499204 New patient, New patient, level 4; level 4; oror

-57 if surgery is -57 if surgery is performed within 3 performed within 3 daysdays

$144$144

9200492004 Comprehensive Comprehensive examexam

-57 if surgery is -57 if surgery is performed within 3 performed within 3 daysdays

$126$126

9201592015 RefractionRefraction N/AN/A Determined Determined by by physicianphysician


9213692136 IOL Master payment IOL Master payment = the global technical = the global technical component and the component and the professional professional component of the component of the right eye; right eye; oror

-RT-RT $86$86

9213692136 -TC -RT -TC -RT -26 -RT-26 -RT

$28 $28 $58$58


V2788V2788 Presbyopia-correcting Presbyopia-correcting function of an intraocular function of an intraocular lens lens for the amount the for the amount the patient pays out-of-patient pays out-of-pocketpocket

-RT-RT

-GY??-GY??

Determined Determined by by physicianphysician


• Exam reveals bilateral cataracts. Exam reveals bilateral cataracts. IOLMaster is orderedIOLMaster is ordered

• Surgery scheduled for the right eyeSurgery scheduled for the right eye

• Patient qualifies for toric IOLPatient qualifies for toric IOL


A9270A9270 Non-covered item or Non-covered item or service, service, for the amount for the amount the patient pays out-of-the patient pays out-of-pocketpocket

-RT-RT

-GY??-GY??

Determined Determined by by physicianphysician

Patient #5 and #6Patient #5 and #6

• What if these patients need a YAG What if these patients need a YAG capsulotomy within the global period?capsulotomy within the global period?

• What if the patients request an IOL What if the patients request an IOL exchange?exchange?

• Can we charge the patient out-of-Can we charge the patient out-of-pocket for these services?pocket for these services?

Patient #5 and #6Patient #5 and #6

6682166821 Laser surgery Laser surgery (eg, YAG (eg, YAG laser) (one or laser) (one or more more sessions)sessions)

-78 -RT-78 -RT $282 $282 Payment will be 80% Payment will be 80% of the allowable. of the allowable. Don’t start a new Don’t start a new global periodglobal period

6698666986 Exchange of Exchange of intraocular intraocular lenslens

-78 -RT-78 -RT $808 $808 Payment will be 80% Payment will be 80% of the allowable. of the allowable. Don’t start a new Don’t start a new global periodglobal period


• This cataract patient is requesting This cataract patient is requesting monovision (one eye distance, one eye monovision (one eye distance, one eye near) following cataract surgery.near) following cataract surgery.

• Are there additional fees a physician Are there additional fees a physician can charge in this situation?can charge in this situation?


• The patient is so pleased with the The patient is so pleased with the outcome of the right eye cataract outcome of the right eye cataract surgery, that within the global period, surgery, that within the global period, surgery on the left eye is scheduled.surgery on the left eye is scheduled.

• A brief exam is performed. Is this a A brief exam is performed. Is this a billable exam?billable exam?

EthicsEthics

Stated here are the Principles and Rules of Stated here are the Principles and Rules of the Code Ethics that may come into play the Code Ethics that may come into play when assigning CPT codes for care provided when assigning CPT codes for care provided to a patient.to a patient.

Ethics - BackgroundEthics - Background

The Principles of Ethics are aspirational and The Principles of Ethics are aspirational and inspirational guidelines, and are not enforceable by the inspirational guidelines, and are not enforceable by the Academy’s Ethics Committee. Academy’s Ethics Committee.

The Rules of Ethics, on the other hand, are mandatory The Rules of Ethics, on the other hand, are mandatory and prescriptive standards of minimally acceptable and prescriptive standards of minimally acceptable conduct and are enforceable by the Academy’s Ethics conduct and are enforceable by the Academy’s Ethics Committee. Committee.

A determination of failure to observe the Code of A determination of failure to observe the Code of Ethics will result in the Academy imposing appropriate Ethics will result in the Academy imposing appropriate sanctions. sanctions.

Principles of Ethics – Principle 5Principles of Ethics – Principle 5

• Fees for Ophthalmological Services.Fees for Ophthalmological Services.

Fees for ophthalmological services Fees for ophthalmological services must not exploit patients or others who must not exploit patients or others who pay for the services.pay for the services.

Example – Principle 5Example – Principle 5

• A patient with AMD is seen for a routine A patient with AMD is seen for a routine exam. The patient has recently gotten a new exam. The patient has recently gotten a new job and now has a new health insurance job and now has a new health insurance provider. This provider is one which the provider. This provider is one which the physician knows is a prompt payer that physician knows is a prompt payer that seldom challenges claims. seldom challenges claims.

Example – Principle 5Example – Principle 5

• The physician orders a fluorescein The physician orders a fluorescein angiography even though there is no angiography even though there is no documented change in the patient’s visual documented change in the patient’s visual fields. fields.

• He states that the reason for the FA is to He states that the reason for the FA is to document the baseline for the new insurance document the baseline for the new insurance company. He continues to order frequent company. He continues to order frequent FAs on a stable patient.FAs on a stable patient.

Rules of Ethics – Rule 3Rules of Ethics – Rule 3

• Clinical Trials and Investigative Procedures.Clinical Trials and Investigative Procedures.

Use of clinical trials or investigative procedures Use of clinical trials or investigative procedures shall be approved by adequate review mechanisms. shall be approved by adequate review mechanisms. Clinical trials and investigative procedures are Clinical trials and investigative procedures are those conducted to develop adequate information those conducted to develop adequate information on which to base prognostic or therapeutic on which to base prognostic or therapeutic decisions or to determine etiology or pathogenesis, decisions or to determine etiology or pathogenesis, in circumstances in which insufficient information in circumstances in which insufficient information exists.exists.


• Clinical Trials and Investigative Clinical Trials and Investigative Procedures.Procedures.

Appropriate informed consent for these Appropriate informed consent for these procedures must recognize their special procedures must recognize their special nature and ramifications.nature and ramifications.


• Dr. Z is a researcher in a clinical trial for an Dr. Z is a researcher in a clinical trial for an investigational corneal trephine. Patients investigational corneal trephine. Patients enrolled in the clinical trial are provided care enrolled in the clinical trial are provided care free-of-charge as part of the parameters of the free-of-charge as part of the parameters of the funded trial. funded trial.

• Patient A volunteered for the clinical trial Patient A volunteered for the clinical trial hoping to benefit from the new device; she has hoping to benefit from the new device; she has corneal dystrophy as well as diminished vision corneal dystrophy as well as diminished vision from nuclear-sclerotic cataracts.from nuclear-sclerotic cataracts.


• Dr. Z orders a series of tests performed on Dr. Z orders a series of tests performed on Patient A relating to her cataract rather than her Patient A relating to her cataract rather than her corneal dystrophy. corneal dystrophy.

• Dr. Z knows these tests will be reimbursed even Dr. Z knows these tests will be reimbursed even though Patient A is involved in the clinical trial though Patient A is involved in the clinical trial solely for treatment with the investigational solely for treatment with the investigational trephine. trephine.


• A doctor is testing a new IOL undergoing final clinical A doctor is testing a new IOL undergoing final clinical trials. He informs the patient that he will perform trials. He informs the patient that he will perform “routine cataract surgery” and expects that the patient “routine cataract surgery” and expects that the patient will be delighted with the outcome. will be delighted with the outcome.

• The special nature of the IOL used is not revealed. The The special nature of the IOL used is not revealed. The surgeon then submits a claim to Medicare for 66984, surgeon then submits a claim to Medicare for 66984, for which he will be reimbursed more than the for which he will be reimbursed more than the manufacturer would pay for the surgery in the clinical manufacturer would pay for the surgery in the clinical trial. trial.


• Pretreatment Assessment.Pretreatment Assessment.

Treatment shall be recommended only after a Treatment shall be recommended only after a careful consideration of the patient's physical, careful consideration of the patient's physical, social, emotional and occupational needs. social, emotional and occupational needs.

The ophthalmologist must evaluate the patient The ophthalmologist must evaluate the patient and assure that the evaluation accurately and assure that the evaluation accurately documents the ophthalmic findings and the documents the ophthalmic findings and the indications for treatment.indications for treatment.


• Pretreatment Assessment.Pretreatment Assessment.

Recommendation of unnecessary treatment Recommendation of unnecessary treatment or withholding of necessary treatment is or withholding of necessary treatment is unethical.unethical.


• Dr. X performs cataract surgery on a patient Dr. X performs cataract surgery on a patient with a pupil that dilates sufficiently to with a pupil that dilates sufficiently to perform cataract surgery, but not as well as a perform cataract surgery, but not as well as a routine case. routine case.

• Dr. X uses iris retractors as a “precaution” Dr. X uses iris retractors as a “precaution” and codes the higher-paying cataract surgery and codes the higher-paying cataract surgery code, 66982.code, 66982.


• Delegation of Services.Delegation of Services.

Delegation is the use of auxiliary health care Delegation is the use of auxiliary health care personnel to provide eye care services for personnel to provide eye care services for which the ophthalmologist is responsible. which the ophthalmologist is responsible.

An ophthalmologist must not delegate to an An ophthalmologist must not delegate to an auxiliary those aspects of eye care within the auxiliary those aspects of eye care within the unique competence of the ophthalmologist unique competence of the ophthalmologist (which do not include those permitted by law to (which do not include those permitted by law to be performed by auxiliaries).be performed by auxiliaries).


When other aspects of eye care for which the When other aspects of eye care for which the ophthalmologist is responsible are delegated to ophthalmologist is responsible are delegated to an auxiliary, the auxiliary must be qualified and an auxiliary, the auxiliary must be qualified and adequately supervised. adequately supervised.

An ophthalmologist may make different An ophthalmologist may make different arrangements for the delegation of eye care in arrangements for the delegation of eye care in special circumstances, so long as the patient's special circumstances, so long as the patient's welfare and rights are the primary welfare and rights are the primary considerations.considerations.


Dr. R performs a routine cataract surgery on Patient S, Dr. R performs a routine cataract surgery on Patient S, an elderly man who is showing signs of senile an elderly man who is showing signs of senile dementia. dementia.

Dr. R’s technician obtains a signature on the consent Dr. R’s technician obtains a signature on the consent form. An uneventful cataract surgery is performed. form. An uneventful cataract surgery is performed.

On the first postop day, Patient S is seen by an On the first postop day, Patient S is seen by an optometrist who routinely sees Dr. R’s postop patients. optometrist who routinely sees Dr. R’s postop patients. Optometrist Q notes in the patient’s chart that she is Optometrist Q notes in the patient’s chart that she is unable to visualize the fundus due to “blood in the unable to visualize the fundus due to “blood in the globe.”globe.”


On postop day three, Patient S complains that his On postop day three, Patient S complains that his vision is distorted and the eye is painful. Optometrist-vision is distorted and the eye is painful. Optometrist-Q, again notes the presence of considerable blood Q, again notes the presence of considerable blood obscuring adequate examination. obscuring adequate examination.

The patient is put on analgesics and asked to return in The patient is put on analgesics and asked to return in two days. On postop day five, the patient complains of two days. On postop day five, the patient complains of no vision and a very painful eye; Optometrist Q refers no vision and a very painful eye; Optometrist Q refers him to a retina specialist who diagnoses a total retinal him to a retina specialist who diagnoses a total retinal detachment. detachment.


Reattachment surgery is performed to no avail; all Reattachment surgery is performed to no avail; all useful vision is lost. useful vision is lost.

Dr. R, the cataract surgeon, discovers this outcome and Dr. R, the cataract surgeon, discovers this outcome and begins to “back code”, indicating that he performed all begins to “back code”, indicating that he performed all the postop care to avoid others learning that he the postop care to avoid others learning that he delegated this patient’s care to an optometrist who, delegated this patient’s care to an optometrist who, although licensed to perform the functions assigned to although licensed to perform the functions assigned to her, was not apparently competent to do so, resulting in her, was not apparently competent to do so, resulting in the loss of the patient’s vision. the loss of the patient’s vision.


• Postoperative Care.Postoperative Care.

The providing of postoperative eye care until the The providing of postoperative eye care until the patient has recovered is integral to patient patient has recovered is integral to patient management. management.

The operating ophthalmologist should provide those The operating ophthalmologist should provide those aspects of postoperative eye care within the unique aspects of postoperative eye care within the unique competence of the ophthalmologist (which do not competence of the ophthalmologist (which do not include those permitted by law to be performed by include those permitted by law to be performed by auxiliaries). auxiliaries).


Otherwise, the operating ophthalmologist Otherwise, the operating ophthalmologist must make arrangements before surgery for must make arrangements before surgery for referral of the patient to another referral of the patient to another ophthalmologist, with the patient's approval ophthalmologist, with the patient's approval and that of the other ophthalmologist.and that of the other ophthalmologist.


The operating ophthalmologist may make different The operating ophthalmologist may make different arrangements for the provision of those aspects of arrangements for the provision of those aspects of postoperative eye care within the unique competence postoperative eye care within the unique competence of the ophthalmologist in special circumstances, such of the ophthalmologist in special circumstances, such as emergencies or when no ophthalmologist is as emergencies or when no ophthalmologist is available, so long as the patient's welfare and rights are available, so long as the patient's welfare and rights are the primary considerations. the primary considerations.

Fees should reflect postoperative eye care Fees should reflect postoperative eye care arrangements with advance disclosure to the patient.arrangements with advance disclosure to the patient.


A cataract surgeon performs an uncomplicated A cataract surgeon performs an uncomplicated cataract surgery by referral from an optometrist. cataract surgery by referral from an optometrist.

In the preoperative consent discussion, there is no In the preoperative consent discussion, there is no discussion of postoperative care arrangements. discussion of postoperative care arrangements.

On the first postoperative day, the surgeon states On the first postoperative day, the surgeon states that the eye is “perfect” and that his job is done. that the eye is “perfect” and that his job is done.


He codes 66984 with modifier 54 for the He codes 66984 with modifier 54 for the surgery and 99024 for the postop visit, and surgery and 99024 for the postop visit, and asks his secretary to schedule a visit with the asks his secretary to schedule a visit with the referring optometrist in one week, whose referring optometrist in one week, whose office is 3 blocks away.office is 3 blocks away.


• Medical and Surgical Procedures.Medical and Surgical Procedures.

An ophthalmologist must not misrepresent An ophthalmologist must not misrepresent the service that is performed or the charges the service that is performed or the charges made for that service.made for that service.


• Dr T has performed a routine cataract Dr T has performed a routine cataract extraction on Patient U. It is now the first extraction on Patient U. It is now the first day postop and Dr. T tells the patient that day postop and Dr. T tells the patient that her eye “looks good,” but there’s some her eye “looks good,” but there’s some “haze to the capsule” so just to be on the “haze to the capsule” so just to be on the “safe side,” he is going to schedule a YAG “safe side,” he is going to schedule a YAG laser capsulotomy in 13 weeks to avoid laser capsulotomy in 13 weeks to avoid “visual loss.” “visual loss.”


The capsule opacity is inconsequential and The capsule opacity is inconsequential and asymptomatic. Nevertheless, the patient is asymptomatic. Nevertheless, the patient is made to understand that there is a serious but made to understand that there is a serious but remediable problem, and gives consent for remediable problem, and gives consent for the procedure. the procedure.

Dr. T performs the YAG capsulotomy the Dr. T performs the YAG capsulotomy the day after the global period for the cataract day after the global period for the cataract surgery has passed, and submits a claim for surgery has passed, and submits a claim for the procedure. the procedure.


Dr. W performs an exam on Patient V who presents Dr. W performs an exam on Patient V who presents with foreign body sensation of three days’ with foreign body sensation of three days’ duration. duration.

Dr. W sees an eyelash floating on the surface of her Dr. W sees an eyelash floating on the surface of her cornea. Dr. W removes the eyelash and checks the cornea. Dr. W removes the eyelash and checks the patient’s other eye for the same reason. Dr. W tells patient’s other eye for the same reason. Dr. W tells Patient V that he did indeed find a foreign body Patient V that he did indeed find a foreign body and removed it. He quickly shows her the surface and removed it. He quickly shows her the surface of a gauze pad on which the “foreign body” lies.of a gauze pad on which the “foreign body” lies.


The patient cannot see the foreign body, but trusts Dr. W The patient cannot see the foreign body, but trusts Dr. W and now feels better. and now feels better.

Dr. W instructs his staff to code the visit:Dr. W instructs his staff to code the visit:

99213-2599213-25 Level 3 established patientLevel 3 established patient $62$626522265222 Removal of foreign body, external eye; Removal of foreign body, external eye;

corneal, with slit lampcorneal, with slit lamp$69$69


Procedures and Materials.Procedures and Materials.

Ophthalmologists should order only those laboratory procedures, optical devices Ophthalmologists should order only those laboratory procedures, optical devices or pharmacological agents that are in the best interest of the patient. Ordering or pharmacological agents that are in the best interest of the patient. Ordering unnecessary procedures or materials or withholding necessary procedures or unnecessary procedures or materials or withholding necessary procedures or materials is unethical.materials is unethical.


Dr. Y sees Patient X for routine visit and notices development of a pigmented choroidal lesion. Dr. Y sees Patient X for routine visit and notices development of a pigmented choroidal lesion. Dr. Y does not order photography to document the size and shape of the lesion because he has Dr. Y does not order photography to document the size and shape of the lesion because he has already ordered X-number of that test this month and ordering another test will cause his already ordered X-number of that test this month and ordering another test will cause his numbers to go “over the top” and will result in less reimbursement under his contract.numbers to go “over the top” and will result in less reimbursement under his contract.


Dr. Y documents the findings, but down-plays the finding in the patient’s Dr. Y documents the findings, but down-plays the finding in the patient’s chart and notes, “Next visit, check status of pigmented lesion.”chart and notes, “Next visit, check status of pigmented lesion.”


• Patient complains of “lesions” left upper lid x 2 Patient complains of “lesions” left upper lid x 2 weeks. Increasing in size, itching, no discharge.weeks. Increasing in size, itching, no discharge.

• Exam reveals two lesions – 0.2 cm in sizeExam reveals two lesions – 0.2 cm in size

• Probably benign – sending to pathology to confirmProbably benign – sending to pathology to confirm

• ABN obtained from patientABN obtained from patient

Patient #9 – Correct codingPatient #9 – Correct coding

11440 Excision, other benign lesion, except skin 11440 Excision, other benign lesion, except skin tag, eyelids, 0.5 cm or lesstag, eyelids, 0.5 cm or less

1.1. CPT code 11440-E1 and 11440-59-E1 CPT code 11440-E1 and 11440-59-E1

2.2. CPT code 11440CPT code 11440

3.3. CPT code 11440-E1 and 11440-51-E1CPT code 11440-E1 and 11440-51-E1

Patient #9 – Correct codingPatient #9 – Correct coding

In addition to the appropriate level of exam In addition to the appropriate level of exam appended by modifier 25appended by modifier 25

2. CPT code 11440. 2. CPT code 11440. Code is payable per session, not Code is payable per session, not per eye, not per lesion.per eye, not per lesion.


Patient c/o “baggy upper lid skin” getting worse Patient c/o “baggy upper lid skin” getting worse over several past yearsover several past years

Exam performed, photographs and VF ordered and Exam performed, photographs and VF ordered and reveal need for combined functional ptosis and reveal need for combined functional ptosis and blepharoplasty proceduresblepharoplasty procedures

• The medical necessity for each procedure was The medical necessity for each procedure was individually documentedindividually documented


• Interpretation and report reads, Interpretation and report reads,

““The visual field defect is related to both ptosis The visual field defect is related to both ptosis and dermatochalasis”and dermatochalasis”

• Question: What is the weak-link in this Question: What is the weak-link in this documentation?documentation?


• In addition to the appropriate level of exam, In addition to the appropriate level of exam, coding should becoding should be

9228592285 External External ocular ocular photographyphotography

Inherently Inherently bilateralbilateral

No No modifiermodifier

CCI bundle CCI bundle with 15823with 15823

(same date)(same date)

$$

9208292082 VF VF Inherently Inherently bilateralbilateral

No No modifiermodifier

N/AN/A $$


• Surgical codingSurgical coding

6790467904 Repair of Repair of blepharoptosis blepharoptosis (tarso) levator (tarso) levator resection or resection or advancementadvancement

-50; or -50; or E1 and E3; E1 and E3; or or RT and RT and LT; and LT; and GAGA

Not bundled Not bundled with 15823with 15823

$662 $662 22ndnd at at 50%50%

1582315823 BlepharoplastyBlepharoplastyexcessive skinexcessive skin

Add -51 to Add -51 to above if above if requiredrequired

Not bundled Not bundled with 67904with 67904

$306 $306 50% 50% reductionreduction


• What if one eye is functional and one is cosmeticWhat if one eye is functional and one is cosmetic??

• Claim submission is not required for the cosmetic Claim submission is not required for the cosmetic eye.eye.

• If patient insists, code 15822-Eye-GY If patient insists, code 15822-Eye-GY Blepharoplasty, upper eyelidBlepharoplasty, upper eyelid

• V50.1 Other plastic surgery for unacceptable V50.1 Other plastic surgery for unacceptable cosmetic appearancecosmetic appearance


• Pt c/o dry eye x several months. +2 burning, Pt c/o dry eye x several months. +2 burning, frequent blinking. Previously tried artificial tears frequent blinking. Previously tried artificial tears & ointment. Uses a humidifier – still no help.& ointment. Uses a humidifier – still no help.

• Schirmer test and exam reveal keratitis OUSchirmer test and exam reveal keratitis OU

• Physician will insert punctal plugs in two lower Physician will insert punctal plugs in two lower punctapuncta



6876168761 Closure of Closure of lacrimal lacrimal punctum; by punctum; by plug, eachplug, each

-50; or RT -50; or RT and LT; or and LT; or E2 and E4E2 and E4

No CCI No CCI editsedits

$137 $137 50% 50% reduction for reduction for second second procedureprocedure


• In 2002 Medicare bundled the supply of the plug In 2002 Medicare bundled the supply of the plug with the insertionwith the insertion

• Non-Medicare payers may pay separately for the Non-Medicare payers may pay separately for the supply of the plugsupply of the plug

HCPCS code A4262 for collagenHCPCS code A4262 for collagen

HCPCS code A4263 for silicone; orHCPCS code A4263 for silicone; or

CPT code 99070 for supply. May require invoiceCPT code 99070 for supply. May require invoice


• There is no CPT code for Schirmer test. There is no CPT code for Schirmer test.

• It is not a countable element of an examIt is not a countable element of an exam

• You can’t bill the patient with the unlisted You can’t bill the patient with the unlisted procedure codeprocedure code


• Following an exam on a glaucoma suspect Following an exam on a glaucoma suspect patient, the physician orders a VF and patient, the physician orders a VF and optic nerve scan on both eyesoptic nerve scan on both eyes



1.1. Bill for the VF and OCT.Bill for the VF and OCT.

2.2. Bill for the optic nerve scan only the two codes are Bill for the optic nerve scan only the two codes are bundled in CCI. Optic nerve scan is payable per bundled in CCI. Optic nerve scan is payable per eye and VF are inherently bilateral.eye and VF are inherently bilateral.

3.3. Have the patient return for any testing as the Have the patient return for any testing as the services are bundled with the exam.services are bundled with the exam.



1.1. Bill for the VF and OCT.Bill for the VF and OCT.

CPT code 92083CPT code 92083 $77$77

CPT code 92135-RTCPT code 92135-RT $45$45

CPT code 92135-LTCPT code 92135-LT $45 (no reduction)$45 (no reduction)


• Many 92135 LCDs state: Many 92135 LCDs state:

- Once per year is appropriate to follow pre-- Once per year is appropriate to follow pre-glaucoma patients or those with “mild damage”glaucoma patients or those with “mild damage”

- Patients with “moderate damage” may be followed - Patients with “moderate damage” may be followed with optic nerve or visual fields. One or two tests with optic nerve or visual fields. One or two tests a year may be appropriate.a year may be appropriate.


• Patient is within the global period of an LPI. An Patient is within the global period of an LPI. An anterior segment B-scans confirms the diagnosis anterior segment B-scans confirms the diagnosis of plateau iris syndrome.of plateau iris syndrome.

• An iridoplasty is scheduledAn iridoplasty is scheduled


7651376513 Anterior segment Anterior segment B-scanB-scan

$98$98 RTRT No CCI No CCI editedit

6676266762 Iridoplasty by Iridoplasty by photocoagulation photocoagulation (one or more (one or more sessions)sessions)

$414$414 Modifier Modifier 78-RT78-RT

No CCI No CCI editedit


• Surgical patient requires an injection of 5FU in the Surgical patient requires an injection of 5FU in the left eye postoperativelyleft eye postoperatively

• The injection, with the appropriate modifier, is The injection, with the appropriate modifier, is payable as is the drugpayable as is the drug

• No office visit is chargedNo office visit is charged


• The correct modifier appended to the injection The correct modifier appended to the injection code is:code is:

1.1. -58-58

2.2. -78-78

3.3. -79-79


6820068200 Subconjunctival Subconjunctival injectioninjection

$39$39 -58 -LT-58 -LT No CCI No CCI editedit

J9190J9190 FluorouracilFluorouracil $$ N/AN/A No CCI No CCI editedit


• Patient requires a scleral patch graft in Patient requires a scleral patch graft in conjunction with placing a drainage conjunction with placing a drainage implant – left eyeimplant – left eye


992XX 992XX or or 9201X9201X

Appropriate Appropriate level of examlevel of exam

$TBD$TBD -57-57 No CCI No CCI editedit

6618066180 Aqueous shunt Aqueous shunt to extraocular to extraocular reservoir reservoir 90-day global90-day global

$1,007$1,007 -LT-LT No CCI No CCI editedit

6725567255 Scleral Scleral reinforcement reinforcement 90-day global 90-day global

$ 374 $ 374 (50%)(50%)

-51 –LT-51 –LT No CCI No CCI editedit


• Patient within a global surgical period Patient within a global surgical period requires removal of sutures. Laser requires removal of sutures. Laser suture lysis is performed.suture lysis is performed.


• Suture removal by laser or other means Suture removal by laser or other means is never payable in the postoperative is never payable in the postoperative periodperiod

• Outside the global period, or if you are Outside the global period, or if you are not the surgeon, it is part of the exam not the surgeon, it is part of the exam code billedcode billed


• It is inappropriate to bill for:It is inappropriate to bill for:

- CPT code 65222 Corneal FB; or- CPT code 65222 Corneal FB; or

- CPT code 66250 Revision, repair of - CPT code 66250 Revision, repair of operative woundoperative wound


• C/O “bump” both C/O “bump” both eyes, nasally on eyes, nasally on the white of the the white of the eye. Eyes are red eye. Eyes are red and irritated.and irritated.


bumpbump

LocationLocation Both eyesBoth eyes

QualityQuality Irritated Irritated DurationDuration


RedRed


• Diagnosis pingueculaDiagnosis pinguecula

- CPT code 68110 Excision of - CPT code 68110 Excision of lesion, conjunctiva; up to 1cm lesion, conjunctiva; up to 1cm ($221); or($221); or

- CPT code 68115 over 1 cm ($312)- CPT code 68115 over 1 cm ($312)


• Diagnosis pterygium Diagnosis pterygium

- CPT code 65420 Excision or - CPT code 65420 Excision or transposition of pterygium; transposition of pterygium; without graft ($493) orwithout graft ($493) or

- CPT code 65426 ($606) with graft- CPT code 65426 ($606) with graft


• Use 65426 regardless of the Use 65426 regardless of the source of the graftsource of the graft

• CCI bundle with amniotic tissue CCI bundle with amniotic tissue transfertransfer


• Patient with progressive Patient with progressive pterygium that needs excision.pterygium that needs excision.

• Surgeon decides to perform at the Surgeon decides to perform at the same surgical encounter as same surgical encounter as cataract surgery in the same eye.cataract surgery in the same eye.


6698466984 Cataract Cataract extraction with extraction with IOL IOL $664$664

Eye Eye modifiermodifier

Not Not bundled bundled with with 6542665426

6542665426 Pterygium Pterygium excision with excision with graft graft $606$606

-51 –eye -51 –eye modifiermodifier

Bundled Bundled with with 6698466984


• Patient with progressive Patient with progressive pterygium (left eye) that needs pterygium (left eye) that needs excision.excision.

• Surgeon decides to perform at the Surgeon decides to perform at the same surgical encounter as same surgical encounter as cataract surgery (right eye)cataract surgery (right eye)


6698466984 Cataract Cataract extraction with extraction with IOL (90-day)IOL (90-day)

$664$664

-RT-RT Not Not bundled bundled with with 6542665426

6542665426 Pterygium Pterygium excision with excision with graft (90-day)graft (90-day)

$303 $303 (50% (50% reduction)reduction)

-59 -LT-59 -LT Bundled Bundled with with 6698466984


• Patient requires cataract Patient requires cataract extraction plus IOL and corneal extraction plus IOL and corneal transplanttransplant

Patient #22 Patient #22

CPT code 65730 RT or LTCPT code 65730 RT or LT $1,560$1,560

CPT code 66984 51 and RT or LTCPT code 66984 51 and RT or LT $ 332$ 332$1,892$1,892

OrOr

CPT code 66984 RT or LTCPT code 66984 RT or LT $ 665$ 665

CPT code 65730 51 and RT or LTCPT code 65730 51 and RT or LT $ 780$ 780$$1,4451,445


Patient requires corneal transplant and IOL Patient requires corneal transplant and IOL exchangeexchange


CPT code 65755 RT or LTCPT code 65755 RT or LT $1,066$1,066

CPT code 66986 51 and RT or LTCPT code 66986 51 and RT or LT $ 404 $ 404 $1,470$1,470

OrOr

CPT code 66986 RT or LTCPT code 66986 RT or LT $808 $808

CPT code 65755 51 and RT or LTCPT code 65755 51 and RT or LT $533 $533 $$1,3411,341


Keratoplasty is the general term for several variants of Keratoplasty is the general term for several variants of corneal transplant. CPT code 65710 covers lamellar corneal transplant. CPT code 65710 covers lamellar keratoplasty in which only the outermost layers of cornea keratoplasty in which only the outermost layers of cornea are transplanted. CPT codes 65730, 65750, and 65755 are transplanted. CPT codes 65730, 65750, and 65755 refer respectively to full-thickness (penetrating) corneal refer respectively to full-thickness (penetrating) corneal transplant in an aphakic patient, an aphakic patient (with transplant in an aphakic patient, an aphakic patient (with no native lens), and a pseudophakic patient (with an no native lens), and a pseudophakic patient (with an artificial lens). The physician work allowance (WRVU) artificial lens). The physician work allowance (WRVU) for each of the three penetrating keratoplasty codes is for each of the three penetrating keratoplasty codes is similar.similar.


A relatively newer procedure is term A relatively newer procedure is term “Descemet’s stripping endothelial keratoplasty “Descemet’s stripping endothelial keratoplasty (DSEK)” or “deep lamellar endothelial (DSEK)” or “deep lamellar endothelial keratoplasty.” This procedure involves a small keratoplasty.” This procedure involves a small incision to allow intraocular placement of incision to allow intraocular placement of endothelium harvested from a donor cornea after endothelium harvested from a donor cornea after the stripping off of diseased corneal the stripping off of diseased corneal endothelium. endothelium.


Microkeratome-based (automated) preparation of Microkeratome-based (automated) preparation of the donor endothelium may be used. This the donor endothelium may be used. This technique offers certain clinical advantages while technique offers certain clinical advantages while achieving the goal of penetrating keratoplasty in achieving the goal of penetrating keratoplasty in patients with disease largely related to endothelial patients with disease largely related to endothelial dysfunction.dysfunction.


Until such time that a more specific code is Until such time that a more specific code is released, many payers are allowing the new released, many payers are allowing the new Descemet’s stripping procedure coded as Descemet’s stripping procedure coded as 65730, 65750, 65755, or 66999 (based on the 65730, 65750, 65755, or 66999 (based on the patient’s lens status). patient’s lens status).

– Offices MUST confirm with the specific Offices MUST confirm with the specific payer that this coding is correctpayer that this coding is correct..


Coding with unlisted procedure code 66999 is Coding with unlisted procedure code 66999 is not incorrectnot incorrect but will trigger delays for but will trigger delays for additional documentation requests, additional documentation requests, processing, review, and cross-walking of processing, review, and cross-walking of reimbursement, and resultant potential access reimbursement, and resultant potential access to care concerns.to care concerns.

Trailblazer states require 66999 for coverage.Trailblazer states require 66999 for coverage.

Explanation of BenefitsExplanation of Benefits

• When processing EOMBs consider:

- How well trained is the staff person?

- See addendum

- Explanation of Medical Benefits, Unlock Its Secrets


• Patient has bilateral lateral rectus resections (both eyes previously underwent strabismus surgery).

• Surgeon also explores the inferior obliques.

Patient #25Patient #256731167311 Strabismus Strabismus

surgery, recession surgery, recession or resection or resection procedure; one procedure; one horizontal musclehorizontal muscle

-50 or RT and LT-50 or RT and LT $516$516

+67331+67331 Strabismus surgery Strabismus surgery on patient with on patient with previous eye previous eye surgerysurgery

-50 or RT and LT-50 or RT and LT

Medicare only allows Medicare only allows payment for one eyepayment for one eye

$260$260

+67340+67340 Strabismus surgery Strabismus surgery involving involving exploration/and or exploration/and or repairrepair

-50 or RT and LT-50 or RT and LT

Medicare only allows Medicare only allows payment for one eyepayment for one eye

$306$306


• In addition to the primary strabismus surgery, the physician performed an adjustable suture.

• But instead of adjusting the suture in the ASC recovery room following surgery, the adjustment was performed in the office the next day.


Can CPT code +67335 Can CPT code +67335 Placement of Placement of adjustable suture(s) during strabismus adjustable suture(s) during strabismus surgery, including postoperative surgery, including postoperative adjustment(s) of suture(s) adjustment(s) of suture(s) be billed when be billed when performed the next day in the office? ($134)performed the next day in the office? ($134)


• Physician orders fundus photography (92250) Physician orders fundus photography (92250) and OCT (92135) performed on the same day. and OCT (92135) performed on the same day.

• The codes are bundled in CCI. The codes are bundled in CCI.

• Is it ever appropriate to unbundle?Is it ever appropriate to unbundle?


• Physician orders optic nerve scan for a Physician orders optic nerve scan for a glaucoma and a retinal diagnosis?glaucoma and a retinal diagnosis?

• Is it ever appropriate to bill 92135 per eye for Is it ever appropriate to bill 92135 per eye for each diagnosis?each diagnosis?


• Physician performed an exam, OCT and an Physician performed an exam, OCT and an injection of Macugen, Avastin, or Lucentis on injection of Macugen, Avastin, or Lucentis on a patient in a skilled nursing home.a patient in a skilled nursing home.

• Are there billing issues?Are there billing issues?

Patient #29Patient #29CPT codeCPT code DescriptionDescription Part B billingPart B billing SNF billingSNF billing

9921X-25 9921X-25 oror

9201X-259201X-25

Appropriate Appropriate level of examlevel of exam

ExamExam

9213592135

Unilateral Unilateral paymentpayment

OCTOCT 92135-26-92135-26-RT 92135-RT 92135-26-LT26-LT

92135-TC-RT 92135-TC-RT 92135-TC-LT92135-TC-LT

6702867028 InjectionInjection 67028-eye67028-eye

HCPCS HCPCS codecode

InjectionInjection DrugDrug


• Skilled nursing facility bill affects coverage Skilled nursing facility bill affects coverage for:for:

- the technical (TC) component of special testing - the technical (TC) component of special testing servicesservices

- post-cataract glasses- post-cataract glasses

- injected drugs- injected drugs

- NTIOLs- NTIOLs

Patient #30 – Retinal casesPatient #30 – Retinal cases

• Tip: Look at the diagnosis, the reason for Tip: Look at the diagnosis, the reason for surgery. The base vitrectomy code will either surgery. The base vitrectomy code will either be a “repair of retinal detachment (RD) code” be a “repair of retinal detachment (RD) code” or a “vitrectomy” code. or a “vitrectomy” code.


Vitrectomy with Epiretinal Membrane StrippingVitrectomy with Epiretinal Membrane Stripping

• Until December 31, 2007 CPT code 67038-eye modifierUntil December 31, 2007 CPT code 67038-eye modifier

• After January 1, 2008After January 1, 2008 CPT code 67041-eye CPT code 67041-eye modifiermodifier


Scleral Buckle, Vitrectomy and Epiretinal Membrane Scleral Buckle, Vitrectomy and Epiretinal Membrane Stripping Stripping

• Until December 31, 2007Until December 31, 2007 CPT CPT code 67038-eye modifier CPT code 67038-eye modifier CPT code 67108-51-eye modifiercode 67108-51-eye modifier

• After January 1, 2008After January 1, 2008 CPT code 67113-eye modifierCPT code 67113-eye modifier


Macular HoleMacular Hole

Until December 31, 2007Until December 31, 2007 CPT code 67038-eye modifierCPT code 67038-eye modifier

After January 1, 2008After January 1, 2008 CPT code 67042-eye modifier CPT code 67042-eye modifier


Macular Hole with Retinal TearMacular Hole with Retinal Tear

• The surgeon finds a retinal tear during surgery to repair a The surgeon finds a retinal tear during surgery to repair a macular hole. The tear is treated by endolaser.macular hole. The tear is treated by endolaser.

Until December 31, 2007Until December 31, 2007 CPT CPT code 67038-eye modifiercode 67038-eye modifier CPT CPT code 67039-eye modifiercode 67039-eye modifier

After January 1, 2008After January 1, 2008 CPT code 67042-eye modifierCPT code 67042-eye modifier


Complex Diabetic Traction Retinal DetachmentsComplex Diabetic Traction Retinal Detachments

Until December 31, 2007Until December 31, 2007 CPT CPT code 67108-eye modifier CPT code 67108-eye modifier CPT code 67038-51-eye modifiercode 67038-51-eye modifier

After January 1, 2008After January 1, 2008 CPT code 67113-eye modifierCPT code 67113-eye modifier


Vitrectomy and Panretinal Photocoagulation for Vitrectomy and Panretinal Photocoagulation for DiabetesDiabetes

For a straight forward vitreous hemorrhage treated with a For a straight forward vitreous hemorrhage treated with a vitrectomy and endophotocoagulationvitrectomy and endophotocoagulation

CPT code 67040-eye modifierCPT code 67040-eye modifier


Vitrectomy and Panretinal Photocoagulation for Vitrectomy and Panretinal Photocoagulation for DiabetesDiabetes

When extensive membrane stripping is done for the When extensive membrane stripping is done for the proliferative disease and endolaser panretinal proliferative disease and endolaser panretinal photocoagulationphotocoagulation

Until December 31, 2007Until December 31, 2007 CPT CPT code 67038-eye modifier CPT code 67038-eye modifier CPT code 67040-51-eye modifiercode 67040-51-eye modifier

After January 1, 2008After January 1, 2008 67040-eye modifier67040-eye modifier

Lens complicationsLens complicationsThe following procedures The following procedures are bundledare bundled with 67036 Vitrectomy, mechanical, with 67036 Vitrectomy, mechanical, pars plana approach; in the CCI.pars plana approach; in the CCI.

6682066820 Discission of secondary membranous cataractDiscission of secondary membranous cataract6683066830 Removal of secondary membranous cataractRemoval of secondary membranous cataract6684066840 Removal of lens material; aspiration techniqueRemoval of lens material; aspiration technique6692066920 intracapsularintracapsular6693066930 intracapsular, for dislocated lensintracapsular, for dislocated lens6694066940 extracapsularextracapsular

Lens complicationsLens complicationsThe next set of three codes The next set of three codes were bundledwere bundled with with 67036 Vitrectomy, mechanical, pars plana 67036 Vitrectomy, mechanical, pars plana approach. approach. Unbundled January 2005. Modifier Unbundled January 2005. Modifier 59 no longer needed.59 no longer needed.

6698266982 Complex cataractComplex cataract6698366983 Intracapsular cataract with IOLIntracapsular cataract with IOL6698466984 Cataract extraction with IOLCataract extraction with IOL

Lens complicationsLens complications

The next set of two codes The next set of two codes were unbundledwere unbundled with with 67036 Vitrectomy, mechanical, pars plana 67036 Vitrectomy, mechanical, pars plana approach. approach. Unbundled April 2003. Modifier 59 Unbundled April 2003. Modifier 59 no longer needed.no longer needed.

6698566985 Secondary IOLSecondary IOL6698666986 IOL exchangeIOL exchange

Lens complicationsLens complications

• If vitrectomy is performed only to If vitrectomy is performed only to accomplish the cataract surgery then it accomplish the cataract surgery then it is integral to the cataract surgery and is integral to the cataract surgery and not separately payable.not separately payable.

Consultations – clarification languageConsultations – clarification language

• ClarificationClarification

A transfer of care occurs when a physician or qualified NPP A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or for the condition and does not expect to continue treating or caring for the patient for that conditioncaring for the patient for that condition..

Tips from the most effective officesTips from the most effective offices


Medicare fee schedule obtained/implemented Medicare fee schedule obtained/implemented by January 1by January 1stst of each year of each year

Non-Medicare fee schedules Non-Medicare fee schedules obtained/implemented after July 1obtained/implemented after July 1stst of each year of each year


Quarterly run a procedure productivity Quarterly run a procedure productivity report for each physician in the practicereport for each physician in the practice

Identify these high-volume utilization Identify these high-volume utilization codescodes


Conduct an internal chart audit of two or Conduct an internal chart audit of two or three of the charts from that particular code three of the charts from that particular code for that period of timefor that period of time

This is the way all payers conduct their This is the way all payers conduct their auditsaudits


Develop a protocol for processing requests Develop a protocol for processing requests for records from any sourcefor records from any source

- Type any notes that aren’t legible- Type any notes that aren’t legible


Sign-up for payer list serves. Develop a Sign-up for payer list serves. Develop a protocol for disseminating pertinent protocol for disseminating pertinent informationinformation


Review current LCDs. These are the rules Review current LCDs. These are the rules and regulations by which you will be held and regulations by which you will be held accountable in an auditaccountable in an audit


Review CCI impact on your coding each quarterReview CCI impact on your coding each quarter

- Coding Bulletin- Coding Bulletin

- Coding Coach- Coding Coach

- - http://www.aao.org/aaoesite/coding/http://www.aao.org/aaoesite/coding/


Develop a protocol for working denials – Develop a protocol for working denials – within 72 hours of EOMB receiptwithin 72 hours of EOMB receipt

Develop a protocol for processing refunds – Develop a protocol for processing refunds – insurance and patientinsurance and patient


Collect all copays, balances owed, Collect all copays, balances owed, refraction charges, etc, at the time of refraction charges, etc, at the time of serviceservice


Stay current with coding issues Stay current with coding issues

- Washington Report- Washington Report

- EyeNet’s Savvy Coder- EyeNet’s Savvy Coder

- AAOE’s Coding Bulletin- AAOE’s Coding Bulletin

- AAOE’s etalk, eexpert, eretina- AAOE’s etalk, eexpert, eretina


Have documentation/coding as a topic at Have documentation/coding as a topic at each staff meetingeach staff meeting

Physician Quality Reporting Physician Quality Reporting InitiativeInitiative

2008 Update2008 Update

PQRI 2008PQRI 2008

• Two components:Two components:

- updates for 2008- updates for 2008

- implementation guide for those who have not - implementation guide for those who have not participated previouslyparticipated previously

PQRI 2008PQRI 2008

• There will not be a question and answer period for There will not be a question and answer period for the call.the call.

• Questions may be submitted to Questions may be submitted to [email protected]@aao.org

- Questions received will be added to the Q&A - Questions received will be added to the Q&A section of section of www.aao.org/pqriwww.aao.org/pqri

PQRI 2008PQRI 2008

• CMS will again provide up to a 1.5 percent bonus CMS will again provide up to a 1.5 percent bonus for physicians who voluntarily report on quality for physicians who voluntarily report on quality measures during 2008, drawing on the $1.35 measures during 2008, drawing on the $1.35 billion Physician Assistance and Quality Initiative billion Physician Assistance and Quality Initiative Fund. PQRI reporting begins January 1, 2008 Fund. PQRI reporting begins January 1, 2008 through December 31, 2008. through December 31, 2008.

PQRI 2008PQRI 2008

• Ophthalmologists are welcome to use any Ophthalmologists are welcome to use any measures that apply to their patient basemeasures that apply to their patient base

• Complete details of all 134 measures can be found Complete details of all 134 measures can be found at at http://www.cms.hhs.gov/PQRI/Downloads/2008Phttp://www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasureSpecs.pdfQRIMeasureSpecs.pdf

PQRI 2008 – PQRI 2008 – Deleted measuresDeleted measures• Measure 13 Age-Related Macular Degeneration: Measure 13 Age-Related Macular Degeneration:

Age-Related Eye Disease Study (AREDS) Age-Related Eye Disease Study (AREDS) Prescribed/Recommended;Prescribed/Recommended;

• Measure 15 Cataracts: Assessment of Visual Measure 15 Cataracts: Assessment of Visual Function Status;Function Status;

• Measure 16 Cataracts: Documentation of Pre-Measure 16 Cataracts: Documentation of Pre-Surgical Axial Length, Corneal Power Measurement Surgical Axial Length, Corneal Power Measurement and Method IOL Power Calculation; andand Method IOL Power Calculation; and

• Measure 17 Cataracts: Pre-Surgical Dilated Fundus Measure 17 Cataracts: Pre-Surgical Dilated Fundus EvaluationEvaluation

PQRI 2008 – PQRI 2008 – Current measuresCurrent measures

• Measure 12, Primary Open Angle Glaucoma: Measure 12, Primary Open Angle Glaucoma: Optic Nerve EvaluationOptic Nerve Evaluation

- addition of modifier 3P. Documentation of system - addition of modifier 3P. Documentation of system reason(s) for not performing an optic nerve head reason(s) for not performing an optic nerve head evaluationevaluation


• Measure 14, Age-Related Macular Degeneration: Measure 14, Age-Related Macular Degeneration: Dilated Macular ExaminationDilated Macular Examination

- addition of modifier 3P. Documentation of - addition of modifier 3P. Documentation of system reason(s) for not performing a dilated system reason(s) for not performing a dilated macular examinationmacular examination


• Measure 18, Diabetic Retinopathy: Measure 18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Documentation of Presence or Absence of Macular Edema and Level of Severity of RetinopathyEdema and Level of Severity of Retinopathy

- addition of modifier 3P. Documentation of - addition of modifier 3P. Documentation of system reason(s) for not performing a dilated system reason(s) for not performing a dilated macular or fundus examinationmacular or fundus examination


• Measure 19, Diabetic Retinopathy: Measure 19, Diabetic Retinopathy: Communication with the Physician Managing Communication with the Physician Managing Ongoing Diabetes CareOngoing Diabetes Care

This measure is now reported using CPT Category This measure is now reported using CPT Category II code II code andand HCPCS G codes. HCPCS G codes.

PQRI 2008 – PQRI 2008 – Measure 19Measure 19

• CPT Category II code 5010F findings of dilated CPT Category II code 5010F findings of dilated macular or fundus exam communicated to the macular or fundus exam communicated to the physician managing the diabetes care, physician managing the diabetes care, andand

• HCPCS G code G8397 Dilated macular or fundus HCPCS G code G8397 Dilated macular or fundus exam performed, including documentation of the exam performed, including documentation of the presence or absence of macular edema and level of presence or absence of macular edema and level of severity of retinopathyseverity of retinopathy


• What if the measure was not performed on a What if the measure was not performed on a qualifying patient?qualifying patient?

PQRI 2008 – PQRI 2008 – Measure 19Measure 19• 5010F5010F

- 2P patient reason for not communicating with 2P patient reason for not communicating with PCP; orPCP; or

- addition of modifier 3P system reason for not addition of modifier 3P system reason for not communicating with PCP; orcommunicating with PCP; or

- 8P findings not communicated, reason not 8P findings not communicated, reason not otherwise specifiedotherwise specified

andand


• G8398 dilated macular or fundus exam not G8398 dilated macular or fundus exam not performedperformed

- no modifier, just the HCPCS G code- no modifier, just the HCPCS G code


• Dilated Eye Exam in Diabetic PatientDilated Eye Exam in Diabetic Patient

• Definition: Percentage of patients aged 18 through Definition: Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who 75 years with a diagnosis of diabetes mellitus who had a dilated eye examhad a dilated eye exam

PQRI 2008 – PQRI 2008 – Measure 117Measure 117• DescriptionDescription

- This measure is to be reported a minimum of once - This measure is to be reported a minimum of once per reporting period for patients with diabetes per reporting period for patients with diabetes mellitus. mellitus.

- This includes patients with diabetes who had one - This includes patients with diabetes who had one of the following: A retinal or dilated eye exam by of the following: A retinal or dilated eye exam by an eye care professional (optometrist or an eye care professional (optometrist or ophthalmologist) during the reporting period, or a ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of retinopathy) negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the by an eye care professional in the year prior to the reporting period. reporting period.


• DescriptionDescription

- For dilated eye exams performed 12 months prior - For dilated eye exams performed 12 months prior to the reporting period, an automated result must to the reporting period, an automated result must be available.be available.

PQRI 2008 – PQRI 2008 – Measure 117Measure 117• CPT Category II CodesCPT Category II Codes

-2022F Dilated retinal eye exam with interpretation by an -2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; orophthalmologist or optometrist documented and reviewed; or

- 2024F Seven standard field stereoscopic photos with - 2024F Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist interpretation by an ophthalmologist or optometrist documented and reviewed; ordocumented and reviewed; or

- 2026F Eye imaging validated to match diagnosis from seven - 2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and standard field stereoscopic photos results documented and reviewed; or reviewed; or

- 3072F Low risk for retinopathy (no evidence of retinopathy - 3072F Low risk for retinopathy (no evidence of retinopathy in the prior year)in the prior year)


• Code the Category II code in addition to the Code the Category II code in addition to the appropriate level of Evaluation and Management appropriate level of Evaluation and Management or Eye code exam: 92002, 92004, 92012, 92014, or Eye code exam: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99220, 99241, 99242, 99243, 99244, 99245, 99455, 9945699455, 99456


• Modifier ApplicationModifier Application

- 8P Dilated eye exam was not performed, reason - 8P Dilated eye exam was not performed, reason not otherwise specifiednot otherwise specified


• Health Information Technology (HIT) - Health Information Technology (HIT) - Adoption/Use of Health Information Technology Adoption/Use of Health Information Technology (Electronic Health Records)(Electronic Health Records)


• DefinitionDefinition

- To qualify, the provider must have adopted a - To qualify, the provider must have adopted a qualified electronic medical record (EMR). For qualified electronic medical record (EMR). For the purpose of the measure, a qualified EMR can the purpose of the measure, a qualified EMR can either be a Certification Commission for either be a Certification Commission for Healthcare Information Technology (CCHIT) Healthcare Information Technology (CCHIT) certified EMR or if not CCHIT certified, the certified EMR or if not CCHIT certified, the system must be capable of all of the following:system must be capable of all of the following:


• Generating a medication listGenerating a medication list

• Generating a problem listGenerating a problem list

• Entering laboratory tests as discrete searchable Entering laboratory tests as discrete searchable data elementsdata elements

• The measure is to be reported at each visit The measure is to be reported at each visit occurring during the report period.occurring during the report period.

PQRI 2008 – PQRI 2008 – Measure 124Measure 124• G Code (instead of Category II code)G Code (instead of Category II code)

- G8447 Patient encounter was documented using a - G8447 Patient encounter was documented using a CCHIT certified EMR; orCCHIT certified EMR; or

- G8448 Patient encounter was documented using a - G8448 Patient encounter was documented using a non-CCHIT certified EMR; ornon-CCHIT certified EMR; or

- G8449 Patient encounter was not documented - G8449 Patient encounter was not documented using an EMR due to system reasons such as using an EMR due to system reasons such as system being inoperable at the time of the visit. system being inoperable at the time of the visit. This implies that an EMR is in place and generally This implies that an EMR is in place and generally availableavailable


• CPT and HCPCS CodesCPT and HCPCS Codes

90801, 90802, 90804, 90805, 90806, 90807, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97001, 97002, 97003, 96150, 96151, 96152, 97001, 97002, 97003, 97004, 97750, 97802, 97803, 97804, 98940, 97004, 97750, 97802, 97803, 97804, 98940, 98941, 98942, 99201, 99202, 99203, 99204, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, D7140, 99241, 99242, 99243, 99244, 99245, D7140, D7210, G0101, G0108, G0109, G0270, G0271D7210, G0101, G0108, G0109, G0270, G0271


• Diagnosis CodesDiagnosis Codes

- No diagnosis codes are associated with this - No diagnosis codes are associated with this measuremeasure

• ModifiersModifiers

- No modifiers are associated with this measure- No modifiers are associated with this measure


• Health Information Technology (HIT) – Health Information Technology (HIT) – Adoption/Use of e-PrescribingAdoption/Use of e-Prescribing

PQRI 2008 – PQRI 2008 – Measure 125Measure 125• DefinitionDefinition

• Qualifying providers have adopted an e-Prescribing system for Qualifying providers have adopted an e-Prescribing system for all patients age 18 years and older and the extent of use in the all patients age 18 years and older and the extent of use in the ambulatory setting. To qualify this system must be capable of ambulatory setting. To qualify this system must be capable of all of the following:all of the following:

• Generating a complete active medication list incorporating Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug electronic data received from applicable pharmacy drug plan(s) if availableplan(s) if available

• Selecting medications, printing prescriptions, electronically Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checkstransmitting prescriptions, and conducting all safety checks

- automated prompts that offer the provider information on the - automated prompts that offer the provider information on the drug being prescribed, potentially inappropriate dose or route drug being prescribed, potentially inappropriate dose or route of administration of a drug, drug to drug interactions, allergy of administration of a drug, drug to drug interactions, allergy concerns, or warnings and cautionsconcerns, or warnings and cautions


• Providing information related to the availability of Providing information related to the availability of lower cost, therapeutically appropriate alternatives lower cost, therapeutically appropriate alternatives (if any)(if any)

• Providing information on formulary or tiered Providing information on formulary or tiered formulary medications, patient eligibility, and formulary medications, patient eligibility, and authorization requirements received electronically authorization requirements received electronically from the patient’s drug planfrom the patient’s drug plan


• HCPCS G CodesHCPCS G Codes

- G8443 All prescriptions created during the encounter - G8443 All prescriptions created during the encounter were generated using a qualified e-Prescribing system; orwere generated using a qualified e-Prescribing system; or

- G8445 No prescriptions were generated during the - G8445 No prescriptions were generated during the encounter; orencounter; or

- G8446 Some or all prescriptions generated during the - G8446 Some or all prescriptions generated during the encounter were handwritten or phoned in due to one of the encounter were handwritten or phoned in due to one of the following: required by state law, patient request, or following: required by state law, patient request, or qualified e-Prescribing system being temporarily qualified e-Prescribing system being temporarily inoperableinoperable


• CPT and HCPCS CodesCPT and HCPCS Codes

• 90801, 90802, 90804, 90805, 90806, 90807, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99215, 99241, 99242, 99243, 99244, 99245, G0101, G0108, G0109G0101, G0108, G0109


• Diagnosis CodesDiagnosis Codes

- No diagnosis codes are associated with this - No diagnosis codes are associated with this measuremeasure

• ModifiersModifiers

- No modifiers are associated with this measure- No modifiers are associated with this measure

PQRI 2008 – PQRI 2008 – Implementation Implementation

PQRI reporting is voluntary, not mandatory.PQRI reporting is voluntary, not mandatory.

• The reporting time frame is January 1 to December The reporting time frame is January 1 to December 31, 2008.31, 2008.


• The bonus is contingent on The bonus is contingent on

(a) achieving 80 percent success for patients that (a) achieving 80 percent success for patients that have a disease/diagnosis that a quality measure have a disease/diagnosis that a quality measure you selected is being reported (e.g., examining the you selected is being reported (e.g., examining the optic nerve for a glaucoma patient) and optic nerve for a glaucoma patient) and

(b) achieving that success rate for three quality (b) achieving that success rate for three quality measures (or fewer measures if less apply).measures (or fewer measures if less apply).


• The bonus will be paid out as a lump sum in mid-The bonus will be paid out as a lump sum in mid-2009.2009.

• The bonus will be applied to 100 percent of Part B The bonus will be applied to 100 percent of Part B billings for the period except for drugs, other billings for the period except for drugs, other biologics and durable medical equipment. There is biologics and durable medical equipment. There is a cap, which ensures that a physician who only a cap, which ensures that a physician who only reports a few cases doesn't get the same size bonus reports a few cases doesn't get the same size bonus as a physician who reports quality measures as a physician who reports quality measures frequently on his/her patients. Congress imposed a frequently on his/her patients. Congress imposed a cap based on a complex formula.cap based on a complex formula.


• There is no need to sign-up to participate. Just There is no need to sign-up to participate. Just begin to report the measures beginning January 1, begin to report the measures beginning January 1, 2008.2008.

• You cannot report on patients seen in nursing You cannot report on patients seen in nursing facilities or in Medicare Advantage programs.facilities or in Medicare Advantage programs.

• Report on Medicare, Railroad Medicare, and Report on Medicare, Railroad Medicare, and Medicare as a secondary payer.Medicare as a secondary payer.


No dollar amount is listed in the Medicare Fee No dollar amount is listed in the Medicare Fee Schedule for the Category II or G codes, but the Schedule for the Category II or G codes, but the charge box should not be left blank. charge box should not be left blank.

If your system or the payer system won’t accept a If your system or the payer system won’t accept a zero charge, post 0.01.zero charge, post 0.01.


Not everyone in the practice has to select the same Not everyone in the practice has to select the same measures. Nor does everyone in the practice need to measures. Nor does everyone in the practice need to participate. participate.

Since the individual reporting is based on the NPI, Since the individual reporting is based on the NPI, only those patients treated by that physician will only those patients treated by that physician will count towards the 80 percent and the bonus count towards the 80 percent and the bonus calculation. However the more participating calculation. However the more participating physicians in the practice, the greater the total physicians in the practice, the greater the total bonus.bonus.


• Begin by selecting the measure(s) applicable to you. Begin by selecting the measure(s) applicable to you.

• Make sure your computer software will accept the Make sure your computer software will accept the Category II and G codes as well as the P modifiers.Category II and G codes as well as the P modifiers.

• Consider running a diagnosis code productivity report Consider running a diagnosis code productivity report from the list of denominators (diagnosis codes) for the from the list of denominators (diagnosis codes) for the measure(s) you’ve selected. This will alert you as to measure(s) you’ve selected. This will alert you as to which additional diagnosis codes are available that you which additional diagnosis codes are available that you might not be using already.might not be using already.

PQRI 2008 – PQRI 2008 – Implementation Implementation • PQRI ModifiersPQRI Modifiers

- There will be situations when a modifier is appropriate in - There will be situations when a modifier is appropriate in addition to the Category II or G code to explain why a addition to the Category II or G code to explain why a measure could not be completed.measure could not be completed.

- 1P Documentation of medical reason(s) for not performing a - 1P Documentation of medical reason(s) for not performing a measure.measure.

- 2P Patient declined for economic, social, or religious - 2P Patient declined for economic, social, or religious reasons.reasons.

- 3P Performance measure exclusion modifier due to system - 3P Performance measure exclusion modifier due to system reasons. Insurance coverage/payer related limitations or reasons. Insurance coverage/payer related limitations or resources to perform the services not available. resources to perform the services not available.

- 8P Reasons not otherwise specified.- 8P Reasons not otherwise specified.

•PQRI for 2009?PQRI for 2009?

PQRI 2009PQRI 2009

• 5 new and 1 revised eye measures have been 5 new and 1 revised eye measures have been approved by the AMA PCPI and AQA approved by the AMA PCPI and AQA

• Not included by CMS in the final ruleNot included by CMS in the final rule

– Academy working to seek implementationAcademy working to seek implementation


Door PrizesDoor Prizes

Welcome to CODEquest 2008!. Congratulations to all who have passed the Ophthalmic Coding Specialist...

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Transcript of Welcome to CODEquest 2008!. Congratulations to all who have passed the Ophthalmic Coding Specialist...