Ophthalmology and Optometry Coding Alert

Visual field testing can take up a lot of the ophthalmologists time, but they often have a problem getting reimbursed. By using the correct diagnosis codes, ophthalmologists can increase their chances of getting paid.

Visual field testing, 92083 (visual field examination, unilateral or bilateral, with interpretation and report; extended examination [e.g., Goldmann visual fields with at least three isopters plotted and static determination within the central 30 degree, or quantitative, automated threshold perimetry Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2 or 30/60-2]) is a test done to check the field of vision for abnormalities such as blind spots or peripheral loss. It is the most extensive of the three visual fields tests and can measure the full capacity of a patients central and peripheral vision.

The test is given for many different indications, including neoplasms, diabetes, migraine, stroke, glaucoma, retinal problems, cataract, eyelid problems and trauma. There are usually few problems with reimbursement for most of these indications.

However, if the test is done due to rheumatoid arthritis, use of high-risk medicine (such as Plaquenil), or lupus, you may need to do some extra listings of diagnoses.

Diagnosis Determines Payment

Rheumatoid arthritis and lupus are handled slightly differently than high-risk medication use. They require you to list any signs and/or symptoms reported by the patient related to visual problems as the primary diagnosis, says Lise Roberts, vice president of Health Care Compliance Strategies of Syosset, NY, and an expert in ophthalmology coding and billing . Then, says Roberts, you should list the underlying condition as the secondary diagnosis.

Whether the underlying condition is rheumatoid arthritis (714.0) or lupus (710.0), you usually are not performing 92083 for that conditionyou usually are performing it because the patient is having some visual symptoms.

If the physician who sent the patient to you for evaluation just wants a baseline examination of the eyes and there are no reported ocular symptoms, the systemic diagnosis must be used as the primary diagnosis, says Roberts. Most Medicare carriers recognize 714.0 and 710.0 as validating diagnoses for 92083.

If the patient is seen while using a high-risk medication such as Plaquenil, code the reason for the visit first as V58.69 (long-term [current] use of other high-risk medications), says Roberts. If the patient is seen after the completion of a high-risk medication course of treatment, use V67.51 (follow-up examination; following completed treatment with high-risk medications, not elsewhere classified).

Code the underlying condition/disease as a secondary diagnosis (714.0 or 710.0).

Although most Medicare carriers recognize that the eyes are connected to the rest of the body and that systemic conditions can often lead to ocular disorders, a few have not yet added all the appropriate systemic diagnoses to their lists of approved diagnoses for visual fields, says Roberts. If you are in an area where your Medicare carrier is not recognizing these diagnoses, contact your state ophthalmological association and request that they act as an intermediary to get the problem fixed with the carrier, she recommends. You can always appeal these cases and typically can win them, but that costs time and money and is a short-term solution that only works to fix the problem with that particular claim.

Jerry Groesch, billing clerk for South Hills Eye Associates of Pittsburgh, PA, uses V67.51 for Plaquenil observation. However, this is for medication that has been completed, and excludes long-term medication. Groesch, who doesnt have a problem getting this paid, always gets a waiver just in case. It is a good idea to get patients to sign a waiver, she says. Even though you get static from some of the patients, and its time-consuming, as a biller I wouldnt do it any other way.

In fact, in the Plaquenil scenario, you would probably first list V58.69 (long-term [current] use of other medications) or V67.51 (follow-up examination; following completed treatment with high-risk medications not elsewhere classified), followed by either lupus (710.0) or rheumatoid arthritis (714.0). These conditions are treated with Plaquenil, a drug that can affect vision and requires regular monitoring.

If a patient is being treated with Plaquenil, and has ocular changes, you would list three diagnoses: V58.69 as the primary (in most states), followed by ocular change symptoms such as 362.10 (background retinopathy) and then by the underlying condition (such as rheumatoid arthritis).

Some carriers have published in their bulletins that they want you to put the ocular change symptoms first, followed by V58.69 for the medication use.

You should always follow any specific instructions found in your Medicare bulletin, Roberts notes. They often have to do with the way that particular carrier has programmed its claims-processing system to recognize the scenario billed for payment rather than denial.