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Ophthalmology and Optometry Coding Alert

Avoid These 6 Pachymetry Coding Pitfalls

Published on Fri Aug 01, 2003

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 of Medicare regs, local carrier requirements and the unwritten rules for reporting 0025T.

2. Linking 0025T to a Non-covered Diagnosis Code

The ICD-9 codes that indicate medical necessity for pachymetry vary dramatically between carriers and if you link a non-covered diagnosis code to 0025T, you can be sure your claim won't make the grade.

Some carriers don't list more than a handful of covered diagnosis code for 0025T. Palmetto GBA, for example, which covers portions of Ohio, South Carolina and West Virginia, currently lists only two ICD-9 codes as supporting medical necessity: 365.01 (Open angle with borderline findings) and 365.04 (Ocular hypertension). On the other hand, Empire Medicare Services (EMS, which covers downstate New York and New Jersey) and National Heritage Insurance Company (NHIC, covering Massachusetts, Maine, New Hampshire and Vermont) offer 12 codes.

But carrier discrepancies don't mean you can't find common coverage ground. Here are some of the commonly cited covered ICD-9 codes for pachymetry: 
 

  •  364.22 Glaucomatocyclitic crises
     
  •  364.77 Recession of chamber angle
     
  •  365.00-365.04 Borderline glaucoma (glaucoma suspect)
     
  •  365.51 Phacolytic glaucoma
     
  •  371.23 Bullous keratopathy
     
  •  371.57 Endothelial corneal dystrophy (Fuchs' only)
     
  •  371.58 Posterior polymorphous dystrophy
     
  •  996.51 Corneal rejection post penetrating keratoplasty

    Currently, most carriers will not reimburse for pachymetry if the patient has a previous diagnosis of glaucoma. In many local areas, ophthalmologists continue to challenge this exclusion and some have been successful in convincing their carrier to cover pachymetry for glaucoma patients.

    Cockrell's office began coding pachymetry as a diagnostic test for glaucoma in 2002 before Cahaba GBA (covering Georgia and Mississippi), their local Medicare carrier, had fully considered the matter. Consequently, Cahaba initially denied the claims as "uncovered services."

    The practice didn't give up, though: The specialists in Cockrell's practice see a large number of glaucoma patients and know their literature. Feeling as though Cahaba's policy did not go far enough and should be expanded to include patients presenting with glaucoma, they built their case for medical necessity, wrote letters justifying the medical need for pachymetry for glaucoma patients, and talked with officials personally, explaining the details of the OHTS finding and their implications on patient treatment.

    The result: Their local carrier revised its local medical review policy (LMRP) to include glaucoma patients. Further, it revised its LMRP to make it one of the most comprehensive and inclusive in the country. Cahaba is one of the few local Medicare carriers whose LMRP includes coverage for existing glaucoma patients. Its list of ICD-9 codes supporting medical necessity includes no less than 47 codes, including a range of glaucoma diagnoses.

    3. Using Additional Modifiers for Bilateral Pachymetry

    One mistake that coders make reporting pachymetry is that they append modifiers to 0025T when it is performed for both eyes at the same patient encounter.

    By definition, 0025T is considered an inherently bilateral procedure in other words, the code already accounts for the work the physician exerts to perform the procedure in both eyes. You should not append modifier -50 (Bilateral procedure) to 0025T nor should you report 0025T twice with the alpha modifiers -RT (right side) and -LT (left side) when the physician performs the procedure bilaterally.

    4. Coding Pachymetry Without Proper Documentation

    Most carriers require that you maintain legible documentation that substantiates the reasonableness and medical necessity of pachymetry, based on their LMRP requirements, chart notes and the test results. You don't necessarily have to submit all of your documentation with the claim, but you must have it readily available should Medicare request to review it. 

    Most carriers designate that pachymetry must be measured with ultrasound for reimbursement which means you'd better document how the pachymetry was measured. If a physician uses a device other than ultrasound (for example, optical coherence tomography), then you should clearly document what was used and append modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to 0025T.

    You also need documentation that the patient meets the frequency limitations for pachymetry. Carriers typically cover pachymetry in their LMRPs once per lifetime, unless there is documented medical necessity to repeat the procedure. For example, a patient with a degenerative disease of cornea may be eligible for more than one pachymetry service. Carriers generally handle these claims on a case-by-case basis.

    5. Neglecting to Use Modifiers for Non-covered Claims

    We're reporting pachymetry and getting the denials, says Christine Fitzgerald, CPC, accounts manager for The Rhode Island Eye Institute. Fitzgerald knows that her local carriers will not reimburse her, but she continues to code 0025T with modifier -GA (Waiver of liability statement on file) and each patient gets an advance beneficiary notice (ABN). It's frustrating, though, she admits, because "the principle here is the patient's eye health, not the money." Although the evidence of medical necessity is there for the reading, for now, her carriers will not pay.

    If your physician feels the claim is medically necessary but there's some doubt that it will be reimbursed, then make sure you provide the patient with notice that Medicare will likely deny payment. Document their consent for the service with an ABN, which indicates the patient takes responsibility for paying for the service.

    If you do not expect your Medicare carrier to reimburse pachymetry, you should modify your coding with one of the following, depending on the circumstances:

  •  -GA If you have established an ABN with the patient, then you will want to add modifier -GA (Waiver of liability statement on file).
     
  •  -GY As mentioned above, if you are measuring pachymetry with a device other than ultrasound, you likely will want to add this modifier, which indicates: "Item or service statutorily excluded or does not meet the definition of any Medicare benefit" (depending on the LMRPs or other carrier policies in your area).
     
  •  -GZ If your physician performs the service outside of the local carriers definition of medical necessity, then you will want to add modifier -GZ (Item or service expected to be denied as not reasonable and necessary).

    6. Opting Out of Documentation Templates

    After you understand the process for successfully submitting pachymetry claims duplicate it! Create appropriate letter and documentation templates to ease processing claims and appealing denials.

    Ask your physician to draft a standard letter of medical necessity, crafted according to the carrier's guidelines to help sidestep errors. The letter provides both a consistent means for documenting medical necessity and a ready piece of evidence for the file should the claim be appealed.

    "Usually you have a CPT code in place and don't have these kinds of hassles," Cockrell says. Once there's a Category I in place in January 2004, she hopes this shouldn't be a problem. "In the meantime, most companies are going to just say, 'Sorry, we don't pay for it. We don't recognize the code; we're not going to pay.'"

    Cockrell says that she could have cut some of the time to payment (and frustration) if she had contacted her local Medicare carrier before submitting her first claim. Given that the ground rules surrounding pachymetry reimbursement are not always clear, you should contact your local Medicare carrier in advance and verify the appropriate coding and filing steps. You should investigate what is covered, how it should be coded, and the documentation requirements for submission and/or to keep in the patient's file.

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