Ophthalmology and Optometry Coding Alert

CCI implements bundles for ophthalmological procedures already covered by global period guidelines.

The newest CCI (Correct Coding Initiative) edits went into effect on July 1, and include more than 14,000 edits that apply to ophthalmologists. CCI 19.2 added almost 293,000 new edits altogether, according to an analysis by Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Focus on E/M Services When Considering New Edits

Digging into the edits is a daunting prospect on the surface, but isn’t so intimidating once you take a closer look.

Here’s why: Virtually every edit associated with opthalmological services includes the same set of approximately 55 E/M codes. E/M services bundled into the procedures include the following sections:

• Patient office visits (99202-99205 for new patients or 99212-99215 for established patients)
• Initial hospital observation care (99218-99220)
• All hospital inpatient E/M services (99221-99239)
•  All inpatient and outpatient consultation services (99241-99255)
• Critical care services (99291 and +99292)
• Nursing facility services (99304-99316)
• Most domiciliary and home services (99324-99350)
• Four codes for care plan oversight services (99374, 99375, 99377, and 99378).

Background: E/M services have always been considered part of a procedure by virtue of the rules defining global periods. Minor procedures (those with 0- and 10-day global periods) may include a minor E/M service that was not “significant and separately identifiable.” Major procedures (with a 90-day global period) have always included any E/M services provided the day of and the day before the procedure.

“The inclusion of the E/M services have always been by definition part of the global period,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Now it seems that CCI wishes to include these included E/M services by virtue of bundles in addition to the global definitions.”

Assume Most Services Override E/M Care

CCI 19.2 includes too many edits involving ophthalmological services to list all the pairs here. Just know that when the services listed in CCI edit pairs are performed during the same encounter as the E/M services listed above, you should only report the diagnostic or therapeutic procedure.

Double Check for Modifier Possibilities

The vast majority of these edits are due to “CPT^® manual or CMS manual coding instructions.” Nearly all edit pairs carry a modifier indicator of “1,” however, meaning that you might sometimes be able to report both services in an edit pair when they’re completed during the same encounter. If you have clear documentation that justifies reporting both services, include that information with your claim and append a modifier (such as 25, Significant, separately identifiable E/M service or 57, Decision for surgery) to the E/M code. 

“So, just like we have always used the 25 and 57 modifiers because of the global rules with minor and major procedures with E/M services, we will continue to use these modifiers when they have been appropriately documented and the circumstances support their use,” Cobuzzi says. “This bundle really has not changed how minor and major procedures with E/M services are coded and handled. It just adds another level to the regulations via the CCI.”