Ophthalmology and Optometry Coding Alert

Many ophthalmologists wonder if they can bill separately for the Schirmer test, which measures tear production. Some ophthalmologists bill for it with 95060 (ophthalmic mucous membrane tests). According to coding experts, this is wrong and could lead to fines.

That is a big no, says Heather Freeland, consultant with Rose and Associates, a compliance, reimbursement, and coding consulting firm specializing in ophthalmology and based in Duncanville, Texas. They cant use 95060 unless they are testing the mucous membrane not the sclera, not the conjunctiva, but the mucous membrane.

Tear testing is part of the eye code (92002, 92004, 92012, 92014) or evaluation and management (E/M) service performed by the physician, says Freeland. "And that makes sense, the consultant says. There are two little pieces of paper, the technician puts them into the lid, rolls them over, and waits five or ten minutes.

In this test, the paper slips are removed and the amount of tears produced is measured by virtue of how far the moisture progressed up the paper slip. The physician doesnt need to be there and often, it is the technician who places the slips and places the result in the medical record. The physician often doesnt even look at the slips themselves.

The test is done by ophthalmologists for a variety of problems, including dry eye syndrome, excess watering, or itchiness, says Freeland. Code 95060, on the other hand, is under allergy testing, and thats what it should be used for, she says.

Some practices use 92499 (unlisted ophthalmological service or procedure) for Schirmer tear testing. This is fine for commercial, non-Medicare payers, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and practice management consulting company in Santa Barbara, Calif. But you cant use 92499 to bill the Schirmer test to Medicare, says Duran. Thats because Medicare views the Schirmer test as being included in the office visit, along with PAM, glare, and sensitivity testing. These are all incidental services that do not have a specific CPT code. Medicare considers that such services are part of the overall visit or consultation code used.

For those practices which are using 92499 to bill the Schirmer test to Medicare and getting paid you may have trouble in the future if you are audited. Medicare says its bundled with the office visit, says Freeland. If you unbundle, you could be fined $2000.

Two thousand dollars per claim? Thats right. They will review a sampling of 10 to 20 charts and apply the error ratio to the universe of similar billed services, explains Duran. Thus, an error ratio of 50 percent for 10 claims that might have been $10,000 can turn into $1,000,000 or more.