Jan EyeCodingForum.com 2012 Coding and Billing Highlights 8 Webinars

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1 Jan EyeCodingForum.com 2012 Coding and Billing Highlights 8 Webinars Jeffrey Restuccio, CPC, CPC-H Memphis TN (901) jeff@eyecodingforum.com 1EyeCodingForum.com

2 2012 Webinar Highlights All eight below and 12 more (2013) are available as a package for $199. You select only the Webinars you want. 2EyeCodingForum.com

3 EyeCodingForum Webinars Individual Webinars are $49 each. Every month we conduct an Eyecare-specific coding and billing Webinar. They are 50 minutes and are typically on Thursday at noon Central time (1:00 pm Eastern time) Every Webinar is recorded and can be reviewed at a later date. It can be paused rewound or fast forwarded just like a video. Packages of Webinars are available in groups of 4 and 8 webinars for $99 and $199, respectively, a 50% discount. You can apply credits to any recorded or future Webinar. Twelve additional Webinars were recorded in All are available on Every Webinar includes valuable information how to increase reimbursement, lower denials, and ensure compliance. 3EyeCodingForum.com

4 May EyeCare Coding and Billing Webinar 1. Overview of common Vision plan scenarios 2. Review of the latest feedback on new 2012 CPT codes. 3. Update of the "Carrier-Specific Guideline" Form. A copy of this form will be made available to all attendees. 4. A quick tour of looking up ICD-9 codes by CPT code (medical necessity) and CPT codes by ICD-9 code (reverse lookup). This is a feature of the EyeCodingForum Coding Advisor a free 30-day trial is available. 5. How to prepare for ICD-10 while still using ICD-9 for the next two years. 4EyeCodingForum.com

5 Floaters (379.24) Medical Necessity (1) Floaters Disorders of vitreous body: other vitreous opacities (floaters) is payable on the following per FL MCR SCODI, anterior segment, with interpretation and report, unilateral or bilateral SCODI, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve SCODI, posterior segment, with interpretation and report, unilateral or bilateral; retina Fundus photography with interpretation and report. 5EyeCodingForum.com

6 Floaters (379.24) Medical Necessity (2) Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent 6EyeCodingForum.com

7 Fundus Photography Medical Necessity Cannot confirm that Diabetes Code 250.0x supports any diagnostic test such as Fundus Photography (92250) or VFE (9208x). Novitas (former Highmark) does not pay on on 250.0x but does pay on the following: Two new 2012 ICD-9 codes are included for this Carrier: OPEN ANGLE WITH BORDERLINE FINDINGS, HIGH RISK PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH RISK MEDICATION NOT ELSEWHERE CLASSIFIED. 7EyeCodingForum.com

8 June EyeCare Coding Webinar 1. Explanation of the Carrier-Specific Rule/Guideline, why you may have never heard of this before and how to create a Carrier-Specific Manual. 2. Updated Carrier Questionnaire form 3. E Codes List. 4. Vitamin Therapy for ARMD and DES. 5. More on ICD-10 codes (feature every month)

9 Punctal Plug Scenario We performed a cataract surgery on the right eye of a patient on 1/31/2012. The patient had a complaint of very dry eyes and the doctor inserted one plug in the left eye and 2 plugs in the right eye on 4/4/2012. The doctor coded (supply) LE, RUL, RLL. Humana paid for the LE and not for the RE due to global period for the Cataract surgery. What are the issues here? 9EyeCodingForum.com

10 Punctal Plug Scenario Modifier 51 means multiple procedures and while most carriers do not require it for this procedure, its use here is not inaccurate LE (this could be lower eyelid or left eyelid it is not clear) E3 (RUL) E4 (RLL) Modifier 24 is an E & M modifier and should not impact non-e & M codes such as punctal plugs insertion. The E1 through E4 modifiers should be used as listed above. The punctal plugs should be linked to the DES ICD-9 code and have nothing to do with the cataract surgery. I would appeal that this was a separate condition; it was in existence before the cataracts, unless there is clinical evidence that cataract removal causes DES. EyeCodingForum.com 10

11 Punctal Plug Scenario I would never report the CPT supply code for the plugs as was done here. The HCPCS codes for the plugs are not paid by any Medicare Carrier (to my knowledge) for the past ten years but a select few private carriers do continue to pay. This is considered a "rare" Carrier-Specific Rule. A4262 TEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACH A4263 PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACH EyeCodingForum.com 11

12 July Webinar: Winning Carrier Appeals / Denied Claims 1. Twelve steps to winning Carrier Denial Appeals. The review will cover: 2. Sample Appeal letters. 3. Most common Optometry Denials 4. Most common reasons claims are denied. 5. Medical necessity, modifiers, LCD s, HCPC codes and all the fundamental concepts 6. Appeal Tips and Tricks you won t learn anywhere else. 7. ICD-10 Corner a short review of how ICD-10 codes will change from the current ICD-9.

13 Top Ten Medicare Part-B Claim Rejections 1. Patient eligibility 2. Referring or Ordering Physician Incorrect 3. Incorrect Procedure Code 4. Incomplete/Invalid Rendering Provider Primary Identifier 5. CLIA Item 6. Medicare Secondary Payor (MSP) 7. Claim not covered by this Payer/Contractor 8. Patient Signature 9. Days/Units 10. Where Services Furnished

14 Top Ten Medicare Part-B Denials (all specialties) 1. Duplicate Claims 2. Medical Necessity 3. Medicare Advantage Plans 4. Provider Eligibility 5. NCCI Edits 6. Screening/Routine 7. Non-Covered Service 8. Patient Supplies 9. Non-Covered Charge 10. Timely Filing

15 Sample Denial scenario/letter State the facts. Be clear on your credentials or background. Be very specific on CPT, ICD-9 and HCPCS rules and guidelines. Always reference Medical Necessity, Modifier rules, NCCI edits, the Bilateral Surgery Modifier and Global Days number as necessary. Be clear that you know the Appeals Process. The more informed you are (and appear) the more likely you will get paid.

16 Twelve Appeal Steps 1. Identify a Rejection VS Denial 2. Get organized before you call 3. Identify the carrier / gather the manual or LCD. 4. Is this a non-covered service? 5. Is pre-authorization always required? 6. ICD-9 Linking 7. NCCI Edit? 8. Correct Modifier? 9. Is this a Carrier-Specific Rule? 10. Is this worth appealing? Can you win? 11. Contact the carrier 12. Appeal as many times (levels) as necessary to get paid.

17 August Webinar: Strategies how to Audit-Proof your documentation Strategies Comprehensive Review of Documentation. Compliance Plan. Don t worry about Red Flags (next slide) Action Plan All files will be included in a zipped file ed to you. EyeCodingForum.com 17

18 You want to be an Outlier Don t worry about Red Flags You want to be an outlier if you are seeing 80-90% medical patients. More diagnostic procedures. More high-level codes (level IV E & M) A lot more revenue. You will still sell glasses. What do you need to make all this happen? EyeCodingForum.com 18

19 Office Visit Exam Four Levels (for E & M Codes) Total Elements = 12 plus 2. Same exam elements for 990xx and 920xx exams. Always match the tests performed to the appropriate level code. 19 EyeCodingForum.com

20 Examination Components - Eye Selecting Exam Elements For the Eye Exam Perform and Document 1 5 exam items from checklist 6 exam items from checklist 9 exam items from checklist Level of Exam Problem Focused (99212/99201) Expanded Problem Focused (99213/99202) Detailed (99214/99203) All 12 Eye and at least 1 (of 2) Neurological/Psychological Comprehensive (99215/99204 / 99205) EyeCodingForum.com 20

21 Examination Components - Eye Selecting Exam Elements (14) - Example PF 1-5 EPF 6 Det 9 Comp VA CF EOM Conjunctiva Pupils/Iris IOP Adnexa Cornea Lens A/C Disks (Dil.) Retina (Dil.) A+OX Mood EyeCodingForum.com 21

22 Sept 5 Webinar Fee Ticket Review By Jeffrey Restuccio, CPC, CPC-H EyeCodingForum.com Memphis TN (901) jeff@eyecodingforum.com 22

23 Areas reviewed E & M codes CPT codes missing Labels / Confusing acronyms Never assume everyone understands vague or confusing or incorrect labels ICD-9 codes vague and incorrect Missing ICD-9 5 th digits and 2 nd code requirements. 23 EyeCodingForum.com

24 Fee Ticket Review Summary This is a hands-on presentation so the Webinar is an on-screen analysis of each Fee Ticket. You don t know what you don t know. Fee Tickets should be reviewed once every year after new codes come out. 24 EyeCodingForum.com

25 October Webinar: 25 Medicare Tips and Tricks E & M codes CPT codes Modifiers NCCI Edits Documentation Linking / Medical Necessity Tips and Tricks 25 EyeCodingForum.com

26 Create a Carrier-Specific Manual Popular procedures All LCD s (Local Coverage Determination) All Carriers Note that there are 15 different Medicare Jurisdictions in the US (will be consolidated to 12) Contracts change. 26 EyeCodingForum.com

27 E & M Code A minimal Provider E & M visit should be a 99212, not a does not require the presence of a Provider. Sometimes referred to as an Incident-To Service (Medicare Concept) Do not report this code whenever a tech performs a test (99211 plus or and pachymetry. It is highly unlikely the claim will be paid. It is a national NCCI edit. If a patient has an IOP check without seeing the provider then a could be reported. If a tech or nurse is providing nutrition-therapy services for ARMD patients including minimal exam elements and History.

28 Medicare Modifier GA MOD-GA - Indicates a non-covered services and requires an Advanced Beneficiary Notice (ABN). Advises patient that the service will not be covered by Medicare and that the patient will be responsible for all charges. Mandatory use date of Revised Form: January 1, Notice is per occurrence. Clinic cannot use a blanket ABN on file. An ABN and MOD-GA not required if the service (i.e., refraction services) is never covered and excluded. EyeCodingForum.com 28

29 Medicare Modifier -GY MOD-GY Clinical Dx not covered by Medicare How is MOD-GY used in Eyecare? Add to Refraction Services when Medicare is primary and the secondary carrier pays on refraction. MOD-GY means the Medicare carrier will deny the claim and crossover to the secondary. The secondary should pay. Note: Some Medicare carriers will cross over without MOD-GY. What should you do? Note: Sometimes the crossover does not automatically work. What should you do? EyeCodingForum.com 29

30 November Webinar: Assume you are new to Medical Billing - examples E & M codes CPT codes Modifiers 23, 25, 59, 26 and TC, GA, GY Documentation Linking / Medical Necessity Tips and Tricks 30 EyeCodingForum.com

31 92015 and a medical Dx NPI Number Use for unlisted codes, co-management and unique situations POAG DES Senile Cataract Moderate stage Units 10/15/ /15/ /15/ , 4 1 1, IS paid by many private medical plans if the ICD-9 code is a medical Dx and not refraction. Paid on cataract. 31

32 Eye Exam and on same day NPI Number Use for unlisted codes, co-management and unique situations V72.0 routine Vision Exam hyperopia Units 10/15/ /15/ Bill linked to V72.0; bill linked to hyperopia. Private carrier. Not Medicare 32

33 Eye Exam and GY; Medicare and 2nd carrier NPI Number Use for unlisted codes, co-management and unique situations POAG hyperopia Moderate stage Units 10/15/ /15/ GY 1, Bill linked to ; bill linked to hyperopia with MOD-GY. Medicare will deny. 2nd carrier pays on hyperopia and

34 December 13 Webinar Marketing to Medical Patients By Jeffrey Restuccio, CPC, CPC-H EyeCodingForum.com Memphis TN (901)

35 Our slant will be unique ways to use coding and billing to market your business. Coding and documentation can be used to market your clinical ability to your patients Documentation is good. Always be chatting up patient s about your medical business. Know your top 5 insurance companies. Print a list of your top 25 ICD-9 and CPT codes. 35 EyeCodingForum.com

36 Vitamin Therapy for ARMD This has multiple benefits. Many ophthalmologists and optometrists do not offer this service. Earn extra income. PQRS elements. Helps meet initiation requirement for 920x4. Also can be used as a counseling visit and a Educate the patient. Ask for referrals. More detail at the end of this presentation. 36 EyeCodingForum.com

37 Other services Mobile Eyecare go to nursing homes. Go to dual-diagnosis (psychiatric) youth home. Any group that has limited mobility. Department of Corrections. Sports vision 37 EyeCodingForum.com

38 Everyone sells Everyone in you office, including the receptionist and the tech s, should be able to explain what is being done and why. This includes the refraction exam, the comprehensive exam as well as the diagnostic tests. Check for a good Eyecare overview. 38 EyeCodingForum.com

39 2012 Webinar Highlights All eight below and 12 more (2013) are available as a package for $199. You select only the Webinars you want. EyeCodingForum.com 39

40 EyeCodingForum Webinars The recorded version of all eight Webinars are available for only $199 per office, which is a 50% discount. Every month in 2013 we will conduct an Eyecare-specific coding and billing Webinar. Each is 50 minutes and are typically Thursday at noon Central time (1:00 pm Eastern time) Every Webinar is recorded and reviewed at a later date. It can be paused rewound or fast forwarded just like a video. Individual Webinars are $49 each. Visit the EyeCodingForum.com Website or contact me at jeff@eyecodingforum.com. EyeCodingForum.com 40