Ophthalmology and Optometry Coding Alert

G0463 edits affect more than 5,000 codes.

Sometimes you’ll see a lull in new Correct Coding Initiative (CCI) edit pairs by the third quarter — but not this year.

The July 1, 2014, CCI version 20.2 update brings 20,729 new edit pairs. “With only 212 terminations, we see a net gain this quarter of 20,517 new edit pairs for a total of 1,334,994 active edit pairs (or reasons not to pay you for what you do) in the database,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

If your ophthalmic surgeon performs procedures in a provider based clinic (also called a provider based entity, or PBE), meaning that the hospital owns the clinic, you might have some concerns when billing 99201-99215 (Office or other outpatient visit for the evaluation and management of a … patient…). That’s because, this year, CMS collapsed that 10-code sequence into a single code that the hospital bills for outpatient payment: G0463 (Hospital outpatient clinic visit for assessment and management of a patient).

Now CMS adds more than 5,000 edit pairs for G0463 (Hospital outpatient clinic visit for assessment and management of a patient) with surgical procedures.

Do this: If your surgeon performs an unrelated evaluation and management service for a hospital outpatient at a PBE, you’ll continue to bill the appropriate code from the range 99201-99215. But the hospital billing for the service would need to check whether the procedure is bundled with G0463 before reporting that code. 

Caveat: These CCI edits won’t apply if you’re billing for your ophthalmic surgeon’s services in most physician offices (place-of-service 11).