Ophthalmology and Optometry Coding Alert

Practices increasingly use pachymetry to diagnose and treat glaucoma and they use the Category III code 0025T to report it. But thanks to complicated coding guidelines and local regulations, confusion, not reimbursement, is on the rise.

"Our physicians see a large number of glaucoma patients, and they feel like the use of pachymetry for diagnosis is the best thing since sliced bread," says Nancy Cockrell, insurance and billing coordinator for Jackson Eye Associates in Mississippi. "It has changed the way they treat people they have been seeing for years."

Others agree. "I got the [pachymeter] because I have a rather large number of glaucoma patients in my practice and felt it important to add this test," says Donald Greenfield, MD, a practicing ophthalmologist in Maplewood, N.J. For the appropriate patient circumstance, this test can be key for diagnosis and treatment strategies, he says.

Don't let your ophthalmologist's pachymetry services go without reimbursement: Take heed of the following pachymetry coding pitfalls to submit clean claims and deter carrier denials. 1. Choosing the Incorrect CPT Code Much of the confusion over coding for pachymetry results from its Category III status. Category III codes are located at the back of the CPT book, and coders often overlook them and report an unlisted procedure code for pachymetry instead of 0025T (Determination of corneal thickness [e.g., pachymetry] with interpretation and report, bilateral).

CMS assigns temporary Category III codes to "emerging technologies, services, and procedures." The designation is an important data collection tool for CMS. By assigning a Category III code to a new technology and requiring health professionals to use it, CMS can then better track the use of the procedure, its effectiveness, and evaluate its appropriateness as a Category I code.

CMS also points out that the Category III procedures, because they are being evaluated, do not carry CMS' endorsement of "clinical efficacy, safety or the applicability to clinical practice."

Because many carriers have a hard time with Category III codes (whether because they consider the service "experimental" or because CPT 0025T contains a pesky alpha character), keep a letter on file explaining the code and the need for the service and know what other information they might require. This can save you time and increase success when fighting denials. When we've had problems with the "non-covered, investigational" denials, we send carriers the standard letter with an explanation of the code and the need for the procedure, says Ellen Janney, CPC, of Valley Family Practice in Roanoke, Va. The high volume of ophthalmologists now performing pachymetry for glaucoma diagnosis and treatment is pressuring CMS to create a CPT Category I code with an assigned fee schedule amount. But until then, the challenge is navigating through the uncertain waters [...]