Ophthalmology and Optometry Coding Alert

And learn how to avoid them Do your physicians know to accurately link the diagnoses listed on the encounter form with the proper procedure codes to support the services rendered? Not according to the most renowned experts in the ophthalmology-coding field.
 
We contacted claims processing personnel at health plans across the country, several coding and reimbursement consultants, and coders in the field to find out the most common errors ophthalmologists' offices make when submitting their claims.
 
Here are the top five sources of claims denials so you can avoid them:

1. Inaccurate Reporting of Diagnosis Codes Incorrect linking. Payers and consultants alike outlined problems with the way practices reported ICD-9 codes and how physicians linked them with corresponding medical procedures.
 
A key issue is the failure to use specific diagnosis codes when they are available, says Catherine Brink, president of Healthcare Resource Management in Spring Lake, N.J.
 
Several coders have complained of rejections when they code 15823 (Blepharoplasty, upper eyelid; with excessive skin weighting down lid).
 
Medicare will often reject this as cosmetic surgery unless you tie it to an appropriate diagnosis code that proves medical necessity, such as 374.30 (Ptosis of eyelid, unspecified) and 374.34 (Blepharochalasis).
 
Misuse of the fifth digit. In many cases, coders also tend to leave off a necessary fifth digit in the ICD-9 code or, in at least a few cases, put on a fifth digit when none is necessary. The carrier will either downcode the claim or send it back to the provider for correction.
 
"Among the claims that we have to pull out and seek more information on, we see a lot of invalid diagnosis codes," says Diana Seymour, manager of front-end claims systems for Blue Cross Blue Shield of Arizona. "What we usually see is an extra zero at the end. What we are finding is that, if we drop the zero, the codes become valid." 2. Improperly Reporting Bilateral Services Errors related to unilateral versus bilateral often cause claims processing problems, according to Michael Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J., and the problem isn't always the fault of the coder.
 
Reporting 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) is especially problematic, says Molly Cross, business operations manager at The Eye Centers of Racine & Kenosha in Wisconsin. "At times, they [carriers] will pay 92235 with modifier -50 (Bilateral procedure),"
Cross says.
 
"Sometimes they want to see two line items with separate eye modifiers. Even Medicare is inconsistent," Cross adds. [...]