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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
NANOS
Diagnosing and Treating Neuro-Ophthalmology
Coding Problems
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Financial Disclosure
Sue Vicchrilli, COT, OCS Academy Coding Executive
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
North American Neuro-Ophthalmology Society 39th Annual Meeting • February 9 - 14, 2013
Snowbird Ski Resort – Snowbird, UT
FINANCIAL DISCLOSURE
I do not have any financial interests or relationships to disclose.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Topics
PQRS/E-Prescribing
Examinations Evaluation and Management
Eye Codes
Testing Services Unilateral/Bilateral
Bundling Edits
Multiple Procedure Payment Reduction
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Financial Disclosure
Modifiers
Surgical Procedures
ICD-10-CM Transition
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
PQRS and
E-Prescribing
Bonus or Penalty?
The Choice is Yours.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS Incentives and Penalties
VBP ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18
PQRS (Successful Participation)
2 2 1 .5 .5 .5
(Not Successful)
-1.5 -2 -2 -2
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
In order to receive 0.5% of all your Medicare Part B,
Medicare as a secondary payer, and
Railroad Medicare allowables (less DME or any injectable drug) . . .
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013 Reporting Options
Option 1:
Report 3 measures correctly 50% of the time via claims (office reporting), or
Option 2:
Report 3 measures correctly 80% of the time via CMS approve registry.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Physicians who fail to participate in
2013 will be subject to a 1.5 percent
payment adjustment in 2015.
• Participating means attempting to report
at least one PQRS measure between
Jan. 1 – Dec. 31, 2013.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Minor changes to current measure
specifications.
• Glaucoma staging codes removed from
measures 12 and 141.
• Measure 124: Health Information
Technology has been eliminated.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Reporting period January 1 through
December 31, 2013 if reporting three
measures via claims or registry.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
15 Ophthalmic Measures
Measure 12
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Measure 14
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Measure 18
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
Measure 19
Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care
PQRS Measures
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
15 Ophthalmic Measures Measure
117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Measure 130
Documentation of Current Medications in the Medical Record
Measure 137
Melanoma: Continuity of Care – Recall System Registry Only
Measure 138
Melanoma: Coordination of Care Registry Only
PQRS Measures
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
15 Ophthalmic Measures Measure
140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Measure 141
Primary Open-Angle Glaucoma (POAG); Reduction of Intraocular Pressure (IOP) by 15 percent or Documentation of a Plan of Care
PQRS Measures
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
15 Ophthalmic Measures
Measure 191
Cataracts: 20/40 or Better Visual Acuity within 90 Days following Cataract Surgery Registry reporting only
Measure 192
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring additional Surgical Procedures Registry reporting only
PQRS Measures
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
15 Ophthalmic Measures
Measure 224
Melanoma: Overutilization of Imaging Studies in Melanoma Registry reporting only
Measure 226
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Measure 265
Biopsy Follow-Up Registry reporting only
Note: All individual measures other than 137, 138, 191, 192, 224, and 265 can be reported via claims or registry.
PQRS Measures
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS: Getting Started
Note: If a patient encounter qualifies
for more than one of the measures
you have selected, report on all that
qualify.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Reminder:
• Not everyone in the practice has to
select the same measures.
• Nor does everyone in the practice need
to participate.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Reminder:
• Reporting is based on the individual
NPI.
• Only those patients treated by that
physician will count towards the bonus
incentive.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Reminder:
• The more participating physicians in the
practice –
◦ The greater the total bonus; and
◦ The greater your ability to avoid the 1.5%
payment adjustment.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Important!
• Make sure your RA has C096 or N365
to verify that the measures have been
reported.
• If the claim is denied, the measure is
denied also and will have to be
resubmitted.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS
Visit www.aao.org/pqrs for all details
Questions? Email [email protected]
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
VBP ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18
“E”RX (Successful Participation)
2 2 1 1 .5
(Not Successful) -1 -1.5 -2
E-Prescribing Incentives and Penalties
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
New: Achieved meaningful use
sometime between Jan. 1, 2011
and June 30, 2012.
New: Registered for the EHR
Incentive program and adopted
EHR between Jan. 2, 2012 and
Jan. 31, 2013.
2013 Automatic Exemptions to E-Prescribing Penalties
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Otherwise
Report G8553 a minimum of 10
times from your office associated
with any billable service (exam,
test, surgery) with dates of service
between now and June 30, 2013, to
avoid the payment adjustment, or
E-Prescribing
Penalties/Payments
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Report G8553 a minimum of 25
times from your office associated
with an exam with dates of service
between now and June 30, 2013, to
receive the payment incentive.
E-Prescribing
Penalties/Payments
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Important!
• Make sure your RA has C096 or N365
to verify that the e-prescription has been
reported.
• If the claim is denied, G8553 is denied
also and will have to be resubmitted.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PQRS 2013
Remember:
• Anything the pharmacy caries can
be e-prescribed.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
January 1, 2013 –
June 30, 2013
10 times to avoid the
2014 penalty – LAST
CHANCE!
Prescription can be
associated with any
Part B service; report
by claims only
CPT code 99024 is not
a reportable service
January 1, 2013 –
December 31, 2013
25 times to earn the
2013 incentive.
Prescription must be
associated with an
office visit; report by
claims or registry
2013/2014 E-Prescribing
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E-Prescribing Resources
Visit www.aao.org/e-rx for all details
Questions? Email [email protected]
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Questions ?
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Evaluation and Management
Eye Codes
Documentation requirements are nationally recognized by all payers.
Documentation requirements may vary by state and by payer.
No limitation on frequency for any payer.
No limitation on frequency for Medicare payers. Non-Medicare payers typically have frequency edits for comprehensive exams.
All diagnosis codes are covered. Limited diagnosis coverage list. Those typically covered can be found at www.aao.org/coding Many systemic disease diagnoses are not covered.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M: History Component
Chief complaint
History of the present illness (HPI)
Review of systems (ROS)
Past, family, and social history
(PFSH)
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M: History Component
Chief complaint
• Does not have to be in the patient’s own
words
• Indicates what elements of the exam
should be performed
• Comprehensive = at least four elements
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
HPI
Location: Right eye, left eye, both eyes?
Context: Associated with any activity?
Quality: Is the nature of the problem constant, acute, chronic, improved or worsening?
Modifying factors: What efforts have been made to improve the problem?
Severity: On a scale of 1-10 Mild, moderate, severe
Associated signs and symptoms: Is the problem causing blurred vision, twitching, headache?
Timing: Worse in am or pm? Onset?
Duration: How long has the issue been a problem?
Brief HPI 1-3 elements
Extended HPI 4-8 elements
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M: History Component
CC: 18-year-old female presents
with progressive field loss OD over
six weeks. Denies eye pain.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
ROS
Constitution Fever, weight loss, cancer
Eyes Sudden loss or change, distortion, double vision, itching, redness, discharge, swelling of lids
Ears, nose, mouth, throat Sinus infection, dry mouth, deafness
Cardiovascular High blood pressure, circulation problems, cholesterol treatment, heart attack
Respiratory Asthma, emphysema, TB
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
ROS
Gastrointestinal Acid – Gerd, hepatitis
Musculoskeletal Arthritis
Neurological Stroke, MS, HOH
Endocrine Diabetes, thyroid
Hematologic/lymphatic Infection
Allergic/immunologic Seasonal allergies, hay fever
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
ROS
Problem pertinent ROS
Only the system in the HPI is reviewed
Extended ROS Two to nine systems are reviewed
Complete ROS Ten or more systems are reviewed
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PFSH
Past history documentation may
include information regarding:
- Prior illnesses and injuries
- Prior operations
- Current medications
- Allergies
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PFSH
Family history documentation may include
information regarding:
• Disease of family member that may be
hereditary or place the patient at risk, such
as diabetes, amblyopia, retinal detachment,
AMD, and glaucoma
• Specific diseases related to problems
identified in the CC or HPI
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PFSH
Social history documentation should
include information regarding:
- Use of drugs, alcohol, and tobacco
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
PFSH
Pertinent history
Only one of the three histories is documented
Complete All three of the histories are documented
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PFSH
All three of the histories must be present
for a new patient or a consultation for
those payers that still recognize those
codes.
Two of three histories must be present
for an established patient.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
PFSH
Information should be referenced
and updated at each visit.
• PFSH no change since (date).
• PFSH no change except__________
since (date).
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Exam • The following elements are
components of the eye examination.
Visual acuity Does not include determination of refractive error.
Gross visual field testing By confrontation
Ocular motility Including primary gaze alignment
Conjunctiva Bulbar and palpebral
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Exam
Ocular adnexa Lids, lacrimal gland, lacrimal drainage, orbits, preauricular nodes
Pupil and iris Shape, direct and consensual reaction (afferent pupil), size, shape, morphology
Cornea (slit-lamp) Epithelium, stroma, endothelium, and tear film
Anterior chamber (slit-lamp)
Depth, cells, flare
Lens (slit-lamp) Clarity, anterior & posterior capsule, cortex, nucleus
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Exam
Intraocular pressure Credit for performance of this element can be counted even when documentation states that IOP measurement has been deferred due to trauma, infection, or poor concentration, or contraindicated
Optic nerve discs Through dilated pupils, unless contraindicated, of size, C/D ratio, appearance such as atrophy, cupping, tumor elevation and nerve fiber layer
Posterior segment including retina and vessels
Through dilated pupils, unless contraindicated, exudates and hemorrhages, atrophy, detachments
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Exam
Brief assessment of mental status including:
Orientation to time, place and person
Mood and affect (eg, depression, anxiety, agitation)
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Exam
Which levels require dilated pupils?
New patient - 99204 and 99205
Established patient – 99215
- unless contraindicated.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Number of Diagnosis and Management Options
Problem Categories Number Points Score
A B C D
Self limited or minor: stable, improved or worsening (Maximum of 2)
1
Established problem: stable or improved 1
Established problem; worsening 2
New problem: no additional work-up planned (Maximum of 1)
3
New problem: additional work-up planned 4
Total
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Number of Diagnosis and Management Options
If the score is 1, the number of
diagnostic/management options is minimal
If the score is 2, the number of
diagnostic/management options is limited
If the score is 3, the number of
diagnostic/management options is multiple
If the score is 4 or more, the number of
diagnostic/management options is extensive
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Amount and/or Complexity of Data
A Points B
Review and/or order of clinical lab tests 1
Review and/or order of radiology/ultrasound (CPT 70000 series or 92136)
1
Review and/or order of medical tests (CPT 90000 series) 1
Discussion of tests with performing physician 1
Independent review of image, tracing, and specimen 2
Decision to obtain old records and/or additional history from other than patient
1
Review of old records and/or additional history from other than patient
2
Total
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Amount and/or Complexity of Data
If the score is 1, the amount and/or complexity of data is minimal or low.
If the score is 2, the amount and/or complexity of data is limited.
If the score is 3, the amount and/or complexity of data is moderate.
If the score is 4 or more, the amount and/or complexity of data is extensive.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Table of Risk
Using the Table of Risk determine the level of
risk for each:
- Presenting problem
- Diagnostic procedure
- Management options
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Level of Risk Presenting Problem(s)
Diagnostic Procedure(s)
Ordered
Management Options Selected
Minimal One self limited or minor problem – cold, insect bite
Lab tests X-rays EKG
Rest, Superficial dressings
Low Two or more self limited or minor problems One stable chronic illness (cataract, diabetes)
Skin biopsies Over the counter drugs Minor surgery with no identified risk factors
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Level of Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options Selected
Moderate One or more chronic illnesses with mild progression Two or more stable chronic illnesses Undiagnosed new problem Acute illness or complicated injury
Endoscopies Obtain fluid from body cavity
Minor surgery with identified risk factors Elective major surgery with no identified risk factors Prescription drug management.
High One or more chronic illnesses with severe progression or side effects of treatment. Acute or chronic illnesses or injuries that post threat to life or bodily function.
Diagnostic endoscopies with identified risk factors
Elective major surgery with risk factors Emergency major surgery
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Final Determination
New Patient – 3/3 components Comprehensive History Comprehensive Exam Moderate Medical Decision Making =
• 99204
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Final Determination
New Patient: 3/3 components Comprehensive History Comprehensive Exam High Medical Decision Making =
• 99205
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Final Determination
Established Patient: 2/3 components: Detailed History Detailed Exam Moderate Medical Decision Making =
• 99214
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Final Determination
Established Patient: 2/3 components: Comprehensive History Comprehensive Exam High Medical Decision Making =
• 99215
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Published Examples
Initial visit for 55-year-old diabetic patient with progressive visual field loss, advanced optic disc cupping and neovascularization of retina.
99205
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Published Examples
Initial visit for 29-year-old female with acute orbital congestion, eyelid retraction, and bilateral visual loss from optic neuropathy.
99205
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Levels of Service Defined
New Patient
99201
Usually the presenting problem(s) are self limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family.
Problem focused history
Problem focused examination
Straightforward MDM
99202
Usually the presenting problem(s) are low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family.
Expanded problem focused history
Expanded problem focused examination
Straightforward MDM
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Levels of Service Defined
New Patient
99203
Usually the presenting problem(s) are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient and/or family.
Detailed history
Detailed examination
Low complexity MDM
99204
Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient and/or family.
Comprehensive history
Comprehensive examination
Moderate complexity MDM
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Levels of Service Defined
New Patient Established Patient
99205
Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient and/or family.
Comprehensive history
Comprehensive examination
High complexity MDM
99211
Commonly referred to as “tech code”.
Usually the presenting problem(s) are minimal.
Typically 5 minutes are spent performing or supervising these services.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Levels of Service Defined
Established Patient Established Patient
99212
Usually the presenting problem(s) are self limited or minor. Typically 10 minutes of physician face-to-face time with the patient and/or family.
Two of these three key components must be documented:
Problem focused history
Problem focused examination
Straightforward MDM
99213
Usually the presenting problem(s) are of low to moderate severity. Typically 15 minutes of physician face-to-face time with the patient and/or family.
Two of these three key components must be documented:
Expanded problem focused history
Expanded problem focused examination
Low complexity MDM
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Levels of Service Defined
Established Patient Established Patient
99214
Usually the presenting problem(s) are moderate or high severity. Typically 25 minutes of physician face-to-face time with the patient and/or family.
Two of these three key components must be documented:
Detailed history
Detailed examination
Moderate MDM
99215
Usually the presenting problem(s) are of moderate to high severity. Typically 40 minutes of physician face-to-face time with the patient and/or family.
Two of these three key components must be documented:
Comprehensive history
Comprehensive examination
High complexity MDM
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Time
When counseling and/or coordination of care constitutes more than 50% of the physician/patient and or family encounter, then time may be considered the key or controlling factor to qualify for a particular E&M service.
Documentation of time must be recorded in the medical record.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Time
Chart notation might read:
- I spent _____ minutes with the patient. I spent more than half of that time providing counseling and coordination of care.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Time
- I spent _____minutes with the patient. I spent
more than half of that time discussing the time
diagnosis and treatment.
- I spent _____ minutes with the patient. I spent
half of that time counseling about the
diagnosis and the importance of taking the
prescribed medication.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Residents and Teaching Physicians
Both residents and teaching physicians may document services in the medical record.
The attending physician who bills Medicare for E&M services, must at a minimum, personally document:
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Residents and Teaching Physicians
- His/her participation in the management of the patient; and
- He/she performed the service or was physically present during the critical or key portions of the service performed by the resident.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
What About Consultations?
Even though CMS eliminated
consultation codes some commercial
payers recognize them.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
What About Consultations?
Two points to remember:
1. Is it really a request for an opinion (consult) or a transfer of care?
2. If Medicare is secondary payer, they will not pay the 20%.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Questions
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Eye Code CPT Description
Intermediate Examination 92002 and 92012
Intermediate ophthalmological services describes an
evaluation of a new or existing condition complicated with
a new diagnostic or management problem not necessarily
relating to the primary diagnosis, including history, general
medical observation, external ocular and adnexal
examination, and other diagnostic procedures as
indicated; may include the use of mydriasis or
ophthalmoscopy.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Intermediate Examination 92002 and 92012
Chief complaint
History
General medical observation
Visual acuity
External ocular exam
Adnexal exam
- May include use of mydriasis or ophthalmoscopy
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014
Comprehensive ophthalmological
services describe a general evaluation
of the complete visual system. The
comprehensive services constitute a
single service entity but need not be
performed in one session.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014
The service includes history, general
medical observation, external and
ophthalmoscopic examination, gross
visual fields, and basic sensorimotor
examination.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014
It often includes as indicated:
biomicroscopy examination with
cycloplegia or mydriasis and tonometry.
It always includes initiation of diagnostic
and treatment programs.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014
Chief complaint
History
General medical observation
Visual acuity
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014
External ocular exam
Gross visual fields
Basic sensorimotor exam
Tonometry
Fundus exam (dilation as medically indicated)
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
CPT Description
Comprehensive Examination 92004 and 92014 Initiation of diagnostic and treatment
program, which includes: - Prescription of medication - Arranging for special diagnostic or
treatment services - Consultations - Lab - Radiological services
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Questions
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
Bottom line:
Determine the appropriate level of
E&M code
Determine the appropriate level of
Eye code
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
Bottom line:
Bill the exam that has the highest
allowable for that payer.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
Bottom line:
This means you need to obtain
the fee schedules for at least your
top five payers.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
CPT code Commercial #1 Commercial #2 Medicare
99201 $80.46 $70 $39.74
99202 $138.57 $123.90 $68.74
99203 $201.90 $177.80 $99.17
99204 $313.65 $273.70 $152.58
99205 $393.36 $345.10 $190.30
92002 $106.82 $129.50 $72.96
92004 $200.02 $240.10 $135.74
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
E&M vs. Eye Codes
CPT code Commercial #1 Commercial #2 Medicare
99211 $39.49 $37.80 $19.13
99212 $80.46 $72.10 $40.07
99213 $134.68 $119.70 $66.81
99214 $202.02 $179.90 $99.18
99215 $272.67 $240.10 $133.47
92012 $112.27 $136.50 $77.28
92014 $164.59 $197.40 $112.25
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Signature Log
Typed Name Legible signature Legible initials Title
John Q. Smith, MD John Q. Smith, MD JQS, MD Physician/MD
Sue J. Vicchrilli, COT Sue J. Vicchrilli,
COT
SJV, COT Certified Technician
Elizabeth Cottle, CPC, OCS
Elizabeth Cottle E.C. Administrator
Barbara Jones Barbara Jones BJ Receptionist
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0
Testing Services
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
It’s All in the Details
1. CPT description
2. Linked diagnosis codes
3. Unilateral/bilateral distinction/modifiers
4. Delegation of tests
5. Interpretation and report
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
It’s All in the Details
6. Technical and professional
component
7. Which tests are bundled with other
tests? Is unbundling appropriate?
8. Advance Beneficiary Notice (ABN)
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
It’s All in the Details
What about frequency edits for
performance?
Unfortunately, rarely published.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Frequency
If in doubt, obtain Advance Beneficiary Notice (ABN) from Medicare patients
Coding Resources (English and Spanish)
www.aao.org/coding
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Audits
Every auditor knows any test that
is delegated (not performed by
the physician) requires a written
order which should state:
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Audits
Which test
Which eye(s)
And the chart note should reflect
medical necessity.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Audits
This must be documented in the medical record (not on the superbill or charge sheet).
Technicians may write the order as dictated by the physician. Physician signature required.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Global Periods
When medically necessary, tests
may be billed (and paid), when
submitted within the global period
of a major or minor surgery.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Testing Services – Skilled nursing facility
Difference between nursing home and
SNF
SNFs receive payment to rehabilitate
the patient.
The technical component of all special
testing services should be submitted to
the SNF and the professional
component to Part B Medicare.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Physician Health Shortage Area
Identified by physician office zip code.
Additional payment for the technical
(-TC) paid on a quarterly basis.
No modifiers necessary.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
92081/92082/92083 Visual Fields
Documentation Unilateral Bilateral
TC 26
CCI Version 19.0
Note of performance and
findings
Bill once when testing one or both
eyes
Yes 92081: 99211, 92082, 92083
92082: 99211, 92083
92083: 99211
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
92133 SCODI - Glaucoma
Documentation Unilateral Bilateral
TC 26
CCI Version 19.0
Note of performance and
findings
Bill once when
testing one or both
eyes
Yes 92132, 99211, 92134, 92227, 92250
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
92134 SCODI - Retina
Documentation Unilateral Bilateral
TC 26
CCI Version 19.0
Note of performance and
findings
Bill once when
testing one or both
eyes
Yes 92132, 99211, 92227, 92250
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
92250 Fundus Photography
Documentation Unilateral Bilateral
TC 26
CCI Version 19.0
Note of performance and
findings
Bill once when
testing one or both
eyes
Yes 99211, 92227
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
92275 Electroretinography
Documentation Unilateral Bilateral
TC 26
CCI Version 19.0
Note of performance and
findings
Bill once when
testing one or both
eyes
Yes 99211
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Testing Services - MPPR
Fortunately, ophthalmology is late to
the reduction-of-payment-for-testing-
services game.
CMS initially applied this concept in
1995 to other specialties.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Testing Services - MPPR
CMS’ analysis of code pairs frequently
performed together revealed evidence of
duplicate payment for many activities.
For example, greeting the patient, taking
his or her history, and collating data were
not performed separately for each test,
but physicians were being paid as though
they were.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Testing Services - MPPR
When any of the following 27 testing
services are performed on the same
day, a 20 percent reduction will be
applied to the technical (-TC)
component of the lowest allowed
amount.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Testing Services - MPPR
76510 76516 92082 92136 92265 92285
76511 76519 92083 92228 92270 92286
76512 92025 92132 92235 92275
76513 92060 92133 92240 92283
76514 92081 92134 92250 92284
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Financial Impact - MPPR
CPT Code Total $ 2013 Professional $ 2013
Technical $ 2013
92250 Fundus Photo
$65.81 $22.60 $43.21
92134 OCT
$43.26 $27.72 $15.53
92083 Visual Field
$61.51 $27.11 $34.39
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Questions ?
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Modifiers
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Modifiers
When in a group practice with
surgical ophthalmologists,
global surgery rules impact
your coding.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Unrelated E&M by same surgeon during postop period
Modifier -24
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Append the modifier to the unrelated office visit.
Management of a problem unrelated to the surgery or in the unoperated eye.
Requires a different diagnosis from the surgical diagnosis code.
Modifier -24
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Modifier -25
Significant, separately identifiable E&M (Eye code too) service by same physician the same day as a minor procedure
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
Modifier -25
Append to the office visit.
To be used when a separately identifiable office visit and a minor surgical procedure are performed on the same day.
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
0 0
26 – Professional component
To be used when the physician
completes only the professional
component of a testing service.
Append the modifier to the testing
service..
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Modifier -79
Unrelated procedure or service by
the same physician during the
postoperative period
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HCPCS modifiers
RT Right side
LT Left side
E1 Left upper lid
E2 Left lower lid
E3 Right upper lid
E4 Right lower lid
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GA ABN on file
GY Deny the claim
GW Patient enrolled in hospice
TC Technical component
HCPCS modifiers
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Questions ?
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Code This Case
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
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Surgery
CPT
Code
Description Global
Period
Physician
Allowable
37609 Ligation or biopsy
temporal artery
Zero-days $319 office
$212 facility
62270 Lumbar puncture Zero-days $137 office
$68 facility
64612 Chemodenervation
of muscle for
blepharospasm
Zero-days $121 office
$108 facility
95857 Myasthenia gravis Zero-days $51 office
$28 facility
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Modifier
When performed the same day as an exam – is it appropriate to append modifier -25 to the exam?
Is the exam significantly, separately identifiable from the minor surgical procedure performed on the same day?
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Questions ?
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ICD-9 ICD-10
ICD-10-CM
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ICD-10-CM
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Everyone who is covered by the
Health Insurance Portability and
Accountability Act (HIPAA) must
make the transition.
• Not just those who submit Medicare
or Medicaid claims.
ICD-10-CM
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ICD-9
446.5
Arteritis: Temporal, giant cell
ICD-10
M31.5
Giant cell arteritis with polymyalgia
rheumatica
M31.6 Other giant cell arteritis
ICD-10-CM
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ICD-9 333.81
Blepharospasm
ICD-10 G24.5
No other code
ICD-10-CM
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ICD-9 348.2Benign intracranial hypertension
ICD-10 G93.2
No other code
ICD-10-CM
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Visual field defect options:
H53.41 Scotoma involving central area
Central scotoma (not billable)
H53.411 Scotoma involving central
area, right eye
H53.412 Scotoma involving central
area, left eye
H53.413 Scotoma involving central
area, bilateral
ICD-10-CM
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Visual field defect options, cont.
H53.42 Scotoma of blind spot area
Enlarged blind spot (not a billable code)
H53.421 Scotoma of blind spot area,
right eye
H53.422 Scotoma of blind spot area,
left eye
H53.423 Scotoma of blind spot area, bilateral
- There are many more options.
ICD-10-CM
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AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES
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What do you code?
• Retrobulbar optic neuritis
• Sudden visual loss
• Headache, tension, episodic, non
intractable
• H53.132, G44.209, H53.8
ICD-10-CM
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How to Get Started
Coders/Billers
• Run a diagnosis productivity report.
• Look up the most frequently diagnosis
codes you use now and convert them
to ICD-10.
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Headache R51
chronic daily R51
cluster G44.009
intractable G44.001
not intractable G44.009
daily chronic R51
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Headache R51
histamine G44.009
intractable G44.001
not intractable G44.009
migraine (type) (see also Migraine)
G43.909
nasal septum R51
neuralgiform, short lasting
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Headache R51
unilateral, with conjunctival
injection and tearing (SUNCT)
G44.059
intractable G44.051
not intractable G44.059
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Headache R51
short lasting unilateral neuralgiform,
with conjunctival
injection and tearing (SUNCT)
G44.059
intractable G44.051
not intractable G44.059
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Headache R51
tension(-type) G44.209
chronic G44.229
intractable G44.221
not intractable G44.229
episodic G44.219
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Headache R51
intractable G44.211
not intractable G44.219
intractable G44.201
not intractable G44.209
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How to Get Started
Coders/Billers
Three to six months prior to ICD-10
implementation
• Code every chart with ICD-10.
◦ Of course only actually submit ICD-9
code.
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How to Get Started
Do not waste time learning the
“tricks of the trade”
• Instead - learn the trade
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Conquering ICD-10 Resources
Website: www.aao.org/icd10
Questions may be emailed to
From those questions a library of
Q&A will be developed.
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Questions ?
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0