Ophthalmology and Optometry Coding Alert

If an auditor comes knocking at your door, be prepared to prove that the ophthalmologist provided the claimed service or procedure -- or that the technician performing the test met certain Medicare rules.

The Office of the Inspector General's (OIG's) recent discovery that unqualified nonphysician practitioners (NPPs) performed 21 percent of incident-to services is sure to have Medicare auditors focused on documentation for claims of commonly performed technician services/procedures.

Many practices believe that as long as they meet the minimum requirements of incident to (the physician is onsiteand sees patients for any new problems), they can report all types of tech services incident to and collect their extra 15 percent of Medicare reimbursement.

In many cases, "physicians feel as long as they can just simply peek in or sit somewhere nearby, they're covered by these rules," unaware that there is more to it for the different types of services these offices perform, suggests Leslie Johnson, CPC, coding supervisor for Duke University Health System and owner of the billing and coding Web site AskLeslie.net.

Reality: "There needs to be a certain level of ongoing involvement," Johnson says. "Coders, billers, and physicians are confused. They may not know the rules, and may be confused by the terminology 'incident to.'" Let the answers to these frequently asked questions guide you toward more effective incident-to coding.

Question: Our tech often performs visual acuity and intraocular pressure (IOP) tests during patient exams. The ophthalmologist is not performing those tests. Can he include them in the exam level list to determine the correct E/M level?

Answer: Yes -- as long as your tech is meeting the incident-to requirements. The tech must be an employee of the practice, and the ophthalmologist must either:

􀀹 be involved in the service that day or

􀀹 have initiated care of the patient, made a plan of care, and remained involved in the patient's care.

The tech must also meet the supervision requirements.

The Medicare Benefit Policy Manual limits incident-to coverage to "situations in which there is direct personal physician supervision."

Medicare takes the "direct supervision" rule quite literally, so make sure you meet the supervision requirement before considering incident to. In short,"direct supervision means the physician is on site and immediately available" during the tech's service, explains Susan Garrison, PCS, FCS, CCS-P, CHC, CPC, CPCH, CPAR, executive vice president of Magnus Confidential Inc. in Atlanta.

Example: The tech performs visual acuity and IOP tests on an established patient. The ophthalmologist tests visual fields and ocular motility, and performs slit-lamp exams of the patient's corneas, lenses, and anterior chambers. The ophthalmologist made medical decisions of low complexity.

Since the ophthalmologist and the tech performed a total of seven tests, the exam portion of the E/M service qualifies as "expanded problem-focused." That and the low-complexity medical decision making (MDM) qualify the service for code 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Watch out: Local coverage determinations may differ in the number of tests required to reach a certain E/M or eye code (92002-92014) level. Check your LCD for specific requirements.

Hidden trap: Don't assume that the tech's write-up of the history of present illness (HPI) will help boost your E/M level. According to Medicare E/M coding guidelines, the physician or non-physician provider (NPP) who  is billing for the E/M service must obtain the HPI. If the tech takes the HPI, the physician or NPP must restate the HPIin the medical record documentation. The provider cannot simply write a statement such as "HPI reviewed and agreed with," or "HPI reviewed and changes or additions as noted." The provider submitting the claim must obtain and document the HPI information.

Question: Fundus photography requires only general supervision. Can we report the technician's services even if the ophthalmologist is not in the office?

Answer: Yes. The incident-to rules don't apply to diagnostic tests, which are governed by separate supervision requirements. You would code these tests under the ordering physician's name and unique physician identification number (UPIN).

What to do: "In the Medicare Fee Schedule, you can find the supervision indicators that describe what Medicare requires for diagnostic tests," says Joan Gilhooly, CPC, PCS, CHCC, president of Medical Business Resources. Look for the requirements for supervision in column AF of the Physician Fee Schedule Database (labeled "Physician Supervision of Diagnostic Procedures").

The number "1" in column AF indicates the test "can be performed under the general supervision of a physician," according to Medicare. The physician maintains overall direction and control of the procedure -- but his presence is not required. In other words, the physician must order the diagnostic test but does not need to be in the office when the technician performs the test.

The following diagnostic tests have a general supervision requirement:

• 92060 -- Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive orparetic muscle with diplopia) with interpretation and report (separate procedure)

• 92065 -- Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

• 92081 -- Visual field examination, unilateral or bilateral, with interpretation and report; limited examination ...

• 92082 -- ... intermediate examination

• 92083 -- ... extended examination

• 92135 -- Scanning computerized ophthalmic diagnostic imaging with interpretation and report, unilateral

• 92250 -- Fundus photography with interpretation and report.

Look for: A "2" in column AF, however, indicates that direct supervision is always necessary. The physician must be present in the office suite and immediately available to direct and assist in the procedure. Tests requiring direct supervision include:

• 92235 -- Fluorescein angiography (includes multiframe imaging) with interpretation and report

• 92240 -- Indocyanine-green angiography (includes multiframe imaging) with interpretation and report.

Note: To read the OIG's report on incident-to reporting, visit www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf.