Ophthalmology and Optometry Coding Alert

In Medicare, the computer that reads your claims determines quickly whether a procedure is "medically necessary" by the diagnosis code you link to it. The problem is, carriers have different medical-necessity lists -- the lists of payable diagnoses by procedure. When you read that one diagnosis may support a procedure in one geographical area, you can't assume that the same is true in your geographical area.
 
Should Physicians See Lists?
 
Compliance experts differ on whether a physician should even see the medical-necessity lists. Such lists can be useful to physicians educated on the fraud and abuse issues related to using codes on the list to the exclusion of other, more appropriate codes. If an ophthalmologist knows which diagnosis codes will support a particular procedure and does not understand his or her obligation to select the most appropriate code -- even if it is not on the list -- he or she would likely pick a code from the list that came somewhat close to the real diagnosis.

However, this would leave out the rest of the ICD-9 choices, which might include an even more appropriate (although not necessarily payable) diagnosis. Allowing a physician to use carrier lists of approved diagnosis codes can result in fraud if the process is used for coding a claim to get paid instead of to represent the accurate condition of the patient. The same problem can occur by using commercially sold "code-link" books and programs.

A real danger of using the list of payable diagnosis codes is that the claim may not be supported by the documentation. Also, not every CPT code is covered by a local medical review policy (LMRP) by every carrier. Educate physicians to select the most accurate ICD-9 code for the condition documented in the medical record.

The bottom line: The ophthalmologist, not the coder, must pick the proper diagnosis. The ophthalmologist may respond: "But what if the one I pick doesn't get the claim paid?" If the one you picked is the best code for the status of the patient and it doesn't get paid, the patient must pay. If, however, the practice has had previous denials for that diagnostic code and fails to get an advance beneficiary notice (ABN) signed by the patient for that visit or procedure, the patient can't be billed. When an office knows a service will be denied because the Medicare carrier does not deem that service reasonable and necessary based on that diagnosis, they should have the patient sign an ABN. This is the major reason why the office staff must know which codes are accepted by their carrier for payment.
 
Visual Field Testing for Patients on Steroids

Patients who have lupus or rheumatoid arthritis undergo steroid treatment. The prescribing physician refers these patients to ophthalmologists to make sure the steroids are not harming vision. To check vision, the ophthalmologist performs visual field testing (92081-92083).

The correct way to list the service is either V58.69 (long-term [current] drug use; long-term [current] use of other medications) or V67.51 (follow-up examination; following other treatment; following completed treatment with high-risk medications, not elsewhere classified). Code either of these as the primary diagnosis. Code the systemic condition -- lupus (710.0) or rheumatoid arthritis (714.0) -- as the secondary diagnosis. Unfortunately, lupus and rheumatoid arthritis are not on most carriers' medical-necessity lists for visual fields. Also, many payers do not recognize V codes.

In Northern California, ophthalmologists asked the carrier (National Heritage Insurance Company) to expand the coverage list of ICD-9 codes for 92081-92083 to include lupus and rheumatoid arthritis, says Raequell Duran, president of Practice Solutions, an ophthalmology coding and consulting firm based in Santa Barbara, Calif. The carrier agreed, she says, and has added 710.0 and 714.0 to the list, so that if billed, and the above V codes aren't used, the service will still be paid. 

Medical-necessity lists also play an important role in the case of a patient with multiple conditions. For example, a patient has nuclear sclerotic cataracts (366.16) and open-angle glaucoma (365.11). The ophthalmologist examines the patient and performs visual field testing, which is done for glaucoma. By mistake, the cataract diagnosis is used to bill the visual field testing and it is denied as not being medically necessary because the cataract diagnosis is not on the coverage list. You would have to send the claim to review explaining that the wrong ICD-9 was used.

Sometimes a patient resists telling the doctor about any signs or symptoms. If the patient reveals no sign, symptom or known diagnostic condition during the normal history-taking, during the examination the doctor should ask questions about symptoms or signs the patient may have been noticing related to what the doctor is finding in the examination, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. "The patient may have thought those not worthy of mentioning," she explains. "The physician can then go back to the chief complaint and history of present illness to add the information."

Rarely does a Medicare-age patient come in for an office visit with no ocular symptom or condition. But when it does occur, Medicare will not cover the service, so the patient pays. John S. Bell, CEO of Maine Eye Associates in Waterville has a 92-year-old patient like this who comes in regularly for routine check-ups. "We never get any complaint out of her," he says.

Sometimes you manage to extricate a chief complaint, only to find out that you can't use it for medical necessity. For example, a patient may have a friend with a retina problem who is slowly going blind, and the patient is too scared to even mention it but just wants to be checked to make sure he or she isn't going to get it. If the patient doesn't have any visual symptoms or known conditions, the patient must pay. This is what Medicare considers a screening examination, which is "routine" and not covered.
 
The Technician Interview
 
Whether you can bill the visit may depend on the way the technician conducts the interview and documents the patient's responses. "You can only code what's written in the medical record," says Nancy McConnell, a consultant with Atlanta-based Gates, Moore & Company.

Typically, the technician obtains the patient's history, including the chief complaint and history of present illness, and performs screening procedures such as visual acuity, intraocular pressure, confrontation visual fields and ocular motility testing, Duran explains. "While the physician may add notations to expand the documentation of the history obtained, the primary responsibility for eliciting the chief complaint is largely the function of the technician," she says.

"Definitely take care of this on the front line whenever possible," Roberts says. "The receptionist can even tell the patient that he or she will be responsible for payment if there's no complaint or problem when scheduling the appointment." He or she can ask the patient the reason for the appointment, and then respond appropriately with insurance coverage information based on what the patient says.

"Don't relegate this job to technicians alone," Duran adds. "After all, telling the patient that he or she will have to pay, just before the doctor walks in, does not put a patient in a great frame of mind for seeing the doctor." It can also result in a "no charge" visit when the physician either feels sympathy for the patient or just wants to get on with the exam.
 
The 'Blurry Vision' Problem
 

If a patient calls for an appointment and says the reason is "blurry vision," the receptionist needs to ask for more information. "You need to have well-trained people answering the phone," McConnell says.

"Blurry vision" is a common chief complaint. It is suitable as a chief complaint, and the visit might be paid, but "blurry vision" is not necessarily payable as a diagnosis by all Medicare carriers. Many conditions cause blurry vision, such as cataracts, corneal dystrophies or macular degeneration, but it could also be a refractive error.

"In general, the signs and symptoms diagnosis codes come in handy, but remember not all LMRPs recognize them," McConnell says. 

"You could say the patient has an irritated eye as the diagnosis, or you could hold the claim and wait until the corneal culture comes back," McConnell says. "My preference is to code the signs and symptoms if those codes are payable." The advantage to coding the signs or symptoms is not having to delay filing a claim to wait for more information.

And if the code isn't payable? "That's when you wait for the report to come back and hope that something more definitive -- and payable -- can be coded," McConnell says.

McConnell recommends that the technician and the physician know about LMRPs and medical-necessity diagnosis codes. "You must train staff to recognize these codes," she says.

Don't look to national Medicare policy for guidance on what diagnosis codes constitute medical necessity for a procedure. Check with your carrier for medical-necessity codes that support certain procedure codes. The individual carriers assign the diagnosis codes with input from their carrier advisory group. National policy delineates the general conditions for which payment can be made, but makes no mention of specific diagnosis codes.