Ophthalmology and Optometry Coding Alert

We talk to many office managers and billers for ophthalmology practices who give up too soon when a claim is denied. They dont want to go through the hassle of an appeal. But they often arent sure of exactly what an appeal would entail. Well, it entails a lot of waiting, but not a lot of time or effort, according to an ophthalmology practice which recently won an appeal that took two years to complete. The practice agreed to talk to us about the process because it believes that if more ophthalmologists appealed denials, such denials would be less routine and more carefully considered by carriers.

The appeal was for procedures which are often denied: 67904 (repair of blepharoptosis; [tarso]levator resection or advancement, external approach) and 15823 (blepharoplasty, upper eyelid; with excessive skin weighting down lid). The ophthalmologist who performed the procedures insisted that they were done for medical necessity, and made it a matter of principle to get Medicare to agree. And, eventually, Medicare did.

But the ophthalmologist had to wait for the right person to whom he could make these arguments. Heres how it happened, with an explanation of what led to the denials, and the process for ultimately winning payment.

1.The first mistake: not doing the external photos or visual fields before surgery. You need to prove to Medicare that these procedures are not for cosmetic purposes. When the first denial came in from Medicare for 67904 and 15823, Michelle Risk, insurance specialist for Thornapple Ophthalmology, a solo practice in Hastings, MI, resubmitted the claim. The original claim had not included external photos (92285) or visual fields (92081-92083) which were not done prior to surgery. Risk says both types of photos and visual fields are required by her Medicare carrier for payment of 67904 and 15823even done separately. Also in this case, both procedures were done bilaterally, and both procedures were done at the same time, so she filed using modifier -50 (bilateral procedure).

Risk thought that it was because of the omission of the external photos and the visual fields that the claim was denied. Blepharoplasty and ptosis repair claims are scrutinized by Medicare for medical necessity, and three thingsexternal photos, visual fields, and the operative noteare essential to get these paid, says Risk. She did send the operative noteand she filed paper claims. Anything that could be cosmetic needs these, she explains. Thats why I sent this on paper. You need to document that the repair is not being done for cosmetic purposes so the photos and visual fields have to show the procedures were medically necessary due to the eyelids drooping down over the field of vision. Thus, when Risk resubmitted the claim, she wrote a letter with it.

Obviously, there were no external photos or visual fields to submit, since this was after the surgery, but there was a measurement of the extra tissue, as well as the patient complaint of difficulty seeing that was documented in the chart. Risk included this information.

So when filing for 67904 and 15823, you must include the following:

92285: external photos, with modifier -50 if bilateral, done prior to surgery;

92081-92083: visual fields, with modifier -50 if bilateral, done prior to surgery;

operative note; and

file on paper, not electronically.

2. Medicares problem: billing 67904 and 15823 together. But it turned out that the lack of visual fields and photos wasnt the problem, when it came to getting paid for both procedures. The problem was that Medicare didnt think 67904 and 15823 should be billed togetherperiod. They said theyre the same, recalls Risk. They said one is inclusive of the other. Both claims were still denied.

Around the same time, another patient required both 67904 and 15823, in both eyes. Again, Risk billed 67904-50 and 15823-50, and this time sent the photos, the visual fields, and the operative note. This time 67904 was paid but 15823 wasnt. The reason was the same as the first denial.

When I called Medicare, they said theyre inclusive, says Risk. This was a big problem from the ophthalmologists viewpoint, because he believed both procedures were medically necessary, but for different reasons.

ABCs of the Medicare Appeals Process

There are three steps to the Medicare appeals process:

A. The medical reviewthe first step. At this point, Michael J. Flohr, MD, the ophthalmologist, felt it was time to ask for a medical review. When a patient has excessive eyelid tissue, he explains, you have to remove the fat pad that is blocking the peripheral vision. That is the blepharoplasty (15823). But if a muscle has also slipped, removing the fat pad alone wont helpyou also need to fix the muscle. This is the ptosis repair (67904). These two patients both had both problems in both eyes.

The medical review is the simplest step, Risk explains. You just call and give the rep the patients Medicare number and the date of service, she says. I explained that the reason for the denial was vague, and we wanted a medical review. All that happens is that the medical director then reviews the claims. The medical review takes a few minutes of the practices time. But the result was negative: Both claims were denied again.

B. The fair hearinganother simple step. At this point, Flohr decided to take the cases to a fair hearing. A fair hearing is the second level of an appeal. It takes more time on the ophthalmologists part, but not more than half an hour (not including travel time, if you want an in-person hearing). You meet before a fair hearing officer, either in person, on the telephone, or via an on-the-record review, in which you dont have to appear in person.

We asked for an in-person hearing, says Risk. The doctor wanted to state his case in person. So Risk wrote a letter to Medicare saying she wanted to have a fair hearing. We received an appointment. The procedures were on schedule. In fact, we only spent about 20 minutes with the hearing officer, she adds.

The result of this meeting was that Medicare would pay for 67904 for both patients, but deny payment for 15823 for both patients. In effect, all the fair hearing did was uphold the medical review. Medicare was insisting that these procedures67904 and 15823cant be billed separately.

C. The administrative law judgeworth waiting for. So Flohr told Risk he wanted to go to the third and final step of a Medicare appeal: an administrative law judge (ALJ). Since their denied claims represented more than $500 (the threshold for an ALJ review; for a fair hearing, its $100), Risk knew this was an option. She wrote a letter to Medicare requesting a meeting with an administrative law judge.

But things happen very slowly at Medicare when you get to this level, because there are few ALJs and they are very busy. Nevertheless, it is the most promising aspect of the appeal if you can wait. Six months later, I called, and they told me that it might take a while because the schedule was full, she relates. At this point, Flohr had some additional information to send. He had copied some pictures from a pertinent article, Risk remembers. We asked Medicare to add it to the file.

Tip: Anything useful you can add while waiting is helpful.

Finally, two years after the initial surgery, the meeting with the ALJ was held. The ophthalmologist, the office manager, and Risk went to the meeting. The ALJ knew the procedures, the situations, all the information for the cases. Then, Flohr explained why he believed the procedures should be paid separately. Three weeks later, she had the letter from Medicarea fully favorable decision. Flohr is getting paid for both the 67904 and the 15823.

The ALJ understood what the doctor was saying, says Risk. If you fix the muscle, and the lid still droops, the patient still cant see. One of the patients had complained about not being able to read, and the other had complained about not being able to see well enough to drive. The patients asked us to fix these problems so they could see better, says Risk.

Yes, it took a long time for the money to finally come through. But it did not take a lot of hands-on time. And it wasnt complicated or frightening. Its just a matter of keeping the documentation and letters in a file. Exhilarated by the success of this, Flohr is beginning the appeal steps now for YAG laser surgery during the post-op period.

Editors Note: Do you have any success stories to share? Any denials resolved by challenging Medicare or commercial insurers? If so, please fax us at 800-508-2592.