Ophthalmology and Optometry Coding Alert

Presented by Regan Bode CPC CMC OCS

The following supplement to Ophthalmology Coding Alert is the slides and transcript of a teleconference presented by The Coding Institute. The speaker Regan Bode CPC OCS is a Certified Procedural Coder (CPC) and an Ophthalmic Coding Specialists (OCS) working for an ophthalmic practice in Bellingham Washington. She has been involved in coding for the past six years and was the first coder to pass the newly created Ophthalmic Coding Specialist exam through the AAO and JCAPHO in March 2004. Regan works closely with the physicians in her group to assure proper coding and compliance and is assisting her front office staff as they work towards passing the OCS exam. She also serves as President of her local coding group.

Thank you everyone for calling in today just a suggestion if questions pop-up during today's teleconference please jot them down so you will remember when we get time at the end to answer some questions and Mandy will give you the instructions for dialing in to answer those.  We will go ahead and get started. 

Complications can arise from any number of sources within your ophthalmic practice.  Some common problems involve our glaucoma patients and the tests and procedures you use to treat these patients.  We will cover some of these common issues - and how to avoid them - in today's session.
 
Glaucoma along with cataract diabetic retinopathy and macular degermation is one of the four leading causes of blindness in adult Americans.  The management of glaucoma includes the early detection and treatment to be able to arrest the loss of vision.  Almost 50% of the patients with glaucoma remain undetected.  30% of glaucoma patients are those with normal intraocular pressure.  Furthermore there are patients with elevated intraocular pressure that do not necessarily have glaucoma.  Dependence upon visual field to separate those patients with glaucoma from those without the disease would still miss a large number of patients.  This is because ganglion cells which enter each optic nerve must be lost before there is a glaucomatous visual field defect created.  Using fundus photograph to detect loss of optic nerve rim tissue may not detect disease until two or more years after visual field loss has occurred.  Additionally some patients cannot perform visual field tests reliably as it is a subjective test requiring a certain level of alertness and cooperation.

Scanning laser glaucoma tests allow earlier detection of glaucoma.  It will distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure.  It may do this before visual fields and/or disc photos could.  This would allow early and efficient efforts for treatment toward the disease process.  We will go into a little bit of information about scanning laser glaucoma tests.  Scanning laser glaucoma diagnostic imaging or CPT code 92135 categorizes the following tests.  It will cover the confocal laser scanning ophthalmoscopy or topography and scanning laser polarimetry nerve fiber analyzer.

The confocal laser scanning topography uses simultaneous stereoscopic video-graphic digitalized images to make quantitative topographic measurements of the optic nerve head and surrounding retina.

Scanning laser polarimetry measures change in the linear polarization of light.  It uses a polarimeter an optical device to measure linear polarization change and scanning laser ophthalmoscope together to measure the thickness of the nerve fiber layer on the retina.  You will commonly hear these tests being referred to as your GDX HRT and OCT.

From here we are going to spend a little time talking about consults and the different types of consults that can come up in your glaucoma or general practice.  One common area for claim denial is inter-office consults.  This is when one physician requests a consult from another physician within the same practice.  It is going to be a problem when we have the same tax identification number.  These types of visits are closely watched by payers and have been subject to heavy chart audits.  To prevent undue attention make sure you follow the rules for a consult.  In order to bill a consult you must have documented the three R's in order to bill.  Those three R's are the request the render and the report back.

The request must be a written request documented in the chart.  When both physicians are in the same office and use the same chart make sure the request is clear in your plan or action section of the chart note.  Render; the physician who received the request must then perform and document their exam.  And the report back even though both provider share the medical record a written report must be dictated back to the requesting provider.  Some carriers might not require the written report back if you are sharing the same chart but definitely check with your carriers for the national standard is that the written report needs to be there.

Inter-office consult should be treated exactly like an outside consult. This will help you from skipping a step - like the report back - just because you are all sharing the same medical record.  Medicare views all ophthalmologists as the same type of physician regardless of subspeciality designation. Your glaucoma specialist and your general ophthalmologist are all in the same eyes of Medicare. You can still bill the consult to Medicare but make sure the visit meets consult requirements and the request for the consult from your glaucoma specialist is well documented.  In a glaucoma specific practice you are accustomed to a large number of consult requests.  Make sure what you are receiving is truly a request for consultation and not a straight referral.

Consults are when a physician's opinion is requested and generally once the exam is performed the report and the patient return to the requesting physician to follow up on the consultant's advice or opinion.  In some cases the requesting physician might ask for the specialist's opinion and then ask the specialist to treat any problems as they see fit.  Once the problem is resolved the patient returns to the requesting physician.  If a physician simply relinquishes care to another provider no reporting back is necessary and you do lose the ability to bill for a consult.

Common activity is for the glaucoma specialist to examine the patient and send back a report.  From the report the glaucoma specialist will work with the requesting physician to determine the next step.  This step might be with the glaucoma specialist and it might be back with the requesting physician.  Either way the exam performed by the specialist is still a consult.

We are going to start touching base on complications that can come up in the postop period.  We are going to cover quite a few different scenarios so this will probably be a good time to make sure if you have questions while we are going through to jot them down for the end.  The complications in the postop period we are on page 13 bottom slide.  The global surgical package includes normal uncomplicated follow-up care according to the definition in CPT.  Certain services associated with surgery are not considered part of the package and are reimbursed separately.  In Medicare's regulations the global surgery package does not include the following:

The initial evaluation by the surgeon to determine the need for surgery.  If the surgeon provided this service on the day of surgery or the day before surgery a modifier-57 and that 57 would be for major surgery so any surgery that has a global day of 90 modifier-57 needs to be added to the office visit.  For any minor procedure add modifier-25 to your office visit.  And a minor would be anything with a global of 0-10 days.

What else is not included would be services of other physicians outside of a group practices unless it is a shared-care surgery or co-management issue.

Any diagnostic tests are not covered in your global and treatment for postoperative complications that require a return trip to the OR.  Medically necessary return trips to the OR for any reason without regard to fault are reimbursed separately but at a reduced rate.

Under the modifier-78 rules the postop clock is not reset so payment for reoperations is the value of the intra-operative service for the CPT code without payment for additional postop care beyond what was included in the first procedure.  To clarify modifier-78 is your return to the OR for a related problem during your global and rather than getting paid for a whole global surgery package you will get reimbursed for the surgical component only and your postop clock will not start or change; it will continue on your original postop dates.

Additional surgery that is prospectively planned as staged procedures.  Staged procedures are planned prospectively at the time of the original procedure.  In these we will be using modifier-58.  Under the modifier-58 rules the postop clock is reset and the surgeon receives reimbursement based on the full allowable amount not just the intraoperative component.  If the less extensive procedure fails and the patient requires a more extensive procedure the payer reimburses for the second procedure separately.  You file your claim for the second surgery with modifier-58 and no reduction is made to the reimbursement.

Other things that are not covered are supply of medications that cannot be self-administered.  For example injectable medications administrated by the surgeon are covered but just note that the active administration itself may not be and you are going to want to check with your carriers to see whether or not they will reimburse you for the injection and the drug or just the drug.  Couple of other things that are not covered in your global are some supplies like bandage contact lenses.

Going into some potential complications of glaucoma surgery.  Glaucoma surgery requires attention special training and skill but problems can arise in even the most routine of cases.  Complications can include patient discomfort hemorrhage endophthalmitis wound thinning hypotony blebitis or an infection in their bleb a bleb leak or bleb failure loss of vision or loss of eye.  Let us look at some specific scenarios to help illustrate how Medicare and most other carriers apply these global surgery rules.

Five days ago the surgeon performed trabeculectomy on a patient who now presents with hyphema.  If the hyphema does not resolve on its own the surgeon will wash out the anterior chamber in the OR.  So if you look at CTP code 65815 it describes the second operation.  We are going to append modifier-78 to our CPT code to indicate that the washout relates to the trabeculectomy because hyphema is a complication of the initial surgery.  Do not select modifier-58 because the trabeculectomy is more extensive than the paracentesis and the washout was not staged.

A different example will be a postop hemorrhage in the posterior chamber.  Yesterday the surgeon performed trabeculectomy on the patient and today the patient presents with suprachoroidal hemorrhage and excruciating pain.  The surgeon needs to drain the suprachoroidal fluid in the OR.  So if you look at CPT code 67015 aspiration or release of vitreous subretinal or choroidal fluid pars plana approach posterior sclerotomy.  This describes the second operation.

While performing the aspiration the surgeon injects balanced salt solution into the anterior chamber to raise the IOP.  Do not report 66020 which is an injection anterior chamber air or liquid separate procedure because this step is an incidental aspect of the draining suprachoroidal fluid and subject to separate procedure rules.  Append modifier-78 to the CPT code to indicate the drainage relates to the trabeculectomy because suprachoroidal hemorrhage is a complication of our original surgery.  Do not select modifier-58 because the trabeculectomy is more extensive than the posterior sclerotomy.

Talking about pre-planned injections of 5-FU near the bleb.  These are fairly common with trabeculectomy surgery.  If the patient is predisposed to inflammation and scarring so the glaucoma surgeon plans to use two antimetabolites mitomycin C and 5-FU.  The surgeon uses mitomycin C at the trabeculectomy and plans for subconjunctival injections of 5-FU for the postop period.  The surgeon will do these 5-FU injections in his or her office.  Pre-planned injections of 5-FU near the bleb continued is code 68200 which describes the subconjunctival injection and describes the component of the 5-FU injection.  Append modifier-58 to show these injections were a staged procedure.  Additionally you will use code J9190 to report the supply of the 5-FU medication.  It is quite common to give multiple injections anywhere from 5-10 during the first two weeks of the postop course.  Consequently the reimbursement ramifications are significant because of the repeated charges.

Now kind of switching a little bit an unplanned injection of 5-FU near the bleb.  Six days ago the surgeon performed trabeculectomy on the patient and today the patient presents with elevated IOP and a failing bleb.  The surgeon injects 5-FU about 1 cm away from the bleb site.  This is done in the office exam lane.  This case is different from the previous case in subtle ways.  Medicare's global surgery package includes all additional medical or surgical services required of the surgeon during the postop period of the surgery because of complications which do not require additional trips to the OR.  You should not file a claim for administering the injection because it is a procedure that does not require return to the OR.  Modifier-58 is not appropriate like it was before because the injection was not pre-planned or staged.  Without a modifier this claim will be bundled with the original trabeculectomy

Going into revising or a revision of the bleb side by needling.  Two weeks ago the patient underwent trabeculectomy.  Since then the bleb has scarred over and failed despite injections of 5-FU.  The surgical staff takes the patient to the OR where an operating microscope is available and a small gauge needle is used to puncture fibrous tissue under the bleb to facilitate filtration.  We will use CPT code 66250 which is a rather generic code but a revision or repair of operative wound of anterior segment any type early or late major or minor; this will be the code for going into needle that bleb.  We are going to append modifier-78 to code 66250 to indicate that the wound revision is a complication of the initial surgery.  You will not select modifier-58 because the trabeculectomy our first surgery is more extensive than the wound revision.

The site of service is a crucial aspect of the reimbursement determination.  If the surgeon believes the same procedure may be safely performed at the slit lamp in the exam lane and does so the global surgery rules would apply and no payment allowed for the needling.  So it must be in the OR for you to use modifier-78 and to get reimbursed.

Going into bandage contact lenses.  Four weeks ago the surgeon performed trabeculectomy with mitomycin C.  In the two weeks following surgery the surgeon gave numerous 5-FU injections.  The patient presents with a flat anterior chamber and hypotony.  The surgeon locates a tear in the conjunctival flap near the limbus and applies glue to the tear then covers with a bandage contact lens.  In this case the gluing is considered a postop complication not requiring a return to the OR and is bundled with the original trabeculectomy.  You can bill for the fitting and supply of the bandaged lens code 92070.

For failure of a primary trabeculectomy; nine weeks ago the surgeon performed primary trabeculectomy.  The surgery failed despite the use of antimetabolites.  The same surgeon returns to the OR and performs another trabeculectomy.  In the presence of scar tissue we are going to use code 66172.  Append modifier-58 to the second trabeculectomy to signify that the second trabeculectomy relates to the first surgery and is more extensive than the original procedure.

For a revision of an aqueous tube shunt; six weeks ago the surgeon implanted an aqueous tube shunt and the patient now presents with elevated IOP.  During the exam the surgeon finds the tube's lumen is occluded; aqueous humor no longer flows from the anterior chamber to the subconjunctival plate.  The surgeon employs a YAG laser to destroy the pigment inside the tube.  CPT code 66185 describes our second procedure will append modifier-78 to the YAG code to indicate that the laser relates to the primary procedure but is not more extensive than the implantation of the shunt.

Diagnostic tests.  Let us not forget that our glaucoma patients undergo surgery for reasons other than glaucoma treatment.  What happens when a glaucoma-related service is needed during these postops?  Luckily Medicare sees diagnostic tests exempt from global surgery rules.  This mean that if a patient underwent a cataract extraction and six weeks later is in for a routine visual field for established primary open-angle glaucoma the visual field can be billed without any modifiers.  If the patient is also seen that day for an IOP check this visit is unrelated to the previous cataract extraction and is not part of the global surgery package.  Bill the appropriate level office visit with a 24-modifier.

Pachymetry; pachymetry is an effective method of measuring corneal thickness.  Corneal thickness can play an important role in getting an accurate intraocular pressure reading.  Unusually thin corneas can cause applanation tonometry readings to yield a false low IOP.  Thick corneas can give a false high IOP reading.  Coverage is limited for pachymetry coverage.  Medicare and most commercial carriers will only except diagnosis codes 365.00 through 365.04 signifying borderline glaucoma and glaucoma suspect.  This coverage is currently limited to a once-in-a-lifetime coverage for patients.

On chart documentation remember that all diagnostic tests need to be recorded in the medical record.  In addition to recording the central corneal thickness measurement you need to include the order for the test the interpretation and report as well as the physician's signature.

Serial tonometry; serial tonometry describes multiple determinations of intraocular pressure over an extended period of time.  This is defined by CPT as three or more readings over six or more hours.  This service includes interpretation and report of all readings.  Why would we perform serial tonometry?  The most common reason serial tonometry is performed is to guide us in the treatment during the course of acute angle-closure glaucoma.  And another time we will use that is when used to asses diurnal variations of IOP in the evaluation and establishment of glaucoma.  Also to establish or exclude glaucoma in patients with optic nerve damage or other signs and symptoms of glaucoma without documentation of elevated IOP.  It is inappropriate to bill for serial tonometry which is CPT code 92100 simply because tonometry is performed more than once during the exam.  Payment for routine measurements of IOP is included in the allowance for general ophthalmologic services or comparable E&M services and this applies even if the measurements are repeated during the exam.  Serial tonometry is not covered when billed for patients who have no optic nerve damage or other signs and symptoms of any type of glaucoma.  Per CPT serial tonometry requires a minimum of 3 readings over six or more hours.  These readings need not to be performed on the same day.  However CTP code 92100 will be paid only once regardless of whether measurements are performed on one or multiple days.

The glaucoma screening benefit.  Medicare covers glaucoma screening once every 12 months for people at a high risk for glaucoma.  This includes people with diabetes a family history of glaucoma or African-Americans who are at the age of 50 or older.  Per Medicare any licensed optometrist or ophthalmologist may perform the glaucoma screening exam.  The glaucoma screening exam can only be billed if it is the only service given to the patient that day.  If they present with any problems or complaints bill the appropriate level office visit for the complaint.  The screen cannot be billed in addition to the complaint exam.  If you find or diagnose glaucoma in a patient presenting for the screen bill that visit as the screen then future exams for treatment of your findings will be covered like normal.

Do not perform diagnostic tests like visual fields on the same day as the screen.  If both are billed Medicare will pay only for the visual field.  Medicare states that the glaucoma screen must include #1 a dilated exam with IOP measurements #2 either a direct ophthalmoscopy exam or a slit lamp biomicroscopic exam.

To report the screening exam use HCPCS code G0117 which is glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist.  The diagnosis code needs to be code V80.1 special screen for neurological eye and ear diseases glaucoma regardless of your findings.  Thank you for joining today.  We will now open up for questions.

Thank you Ms. Bode.  Ladies and gentlemen I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time please press *1 on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue please press #.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1.  Our first question comes from Robert List of Chester County Eye Care. 

Please state your question.

Q & A Session:

Question:  In regards to serial tonometry coding limitations if the CPT code is billed once over multiple days is that in addition to billing for office visits on those multiple days?

Answer:  Correct.  If you met the requirements to bill any type of office visit you could of course bill those.  It is just the tonometry that cannot be billed.

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Question:  So if I specify that I want to patient to come back say for the next three of four visits at different times purely so I can get their pressures at different times those three or four visits I can bill the appropriate E&M code and then on say the fourth visit bill the serial tonometry and explain on the chart that they were different times for that reason?

Answer:  Correct.

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Question:  In regards to lasering sutures after trabeculectomy when I do them within the first few weeks after trabeculectomy there are no charges to the patients?

Answer:  Correct.

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Question: There is no bleb or vision or anything am I doing that correctly?

Answer:  Correct.  There is no code for going in and lasering those sutures.

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Question:  Thank you for the forum.  Extensive ophthalmoscopies in regards to glaucoma; if the patient comes in with a disc hemorrhage or obvious focal change in the optic nerve.  If the photographer is not present at the time and therefore I draw where the hemorrhage is on the optic nerve because there is no photographer at that time am I permitted to bill extensive ophthalmoscopy?

Answer:  Well by having a photographer do you usually have someone else who would perform your extended ophthalmoscopy or you talking about going to get fundus photos or disc photos?

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Question:  Well generally if I see an optic nerve hemorrhage that is new I would take a photograph of it.  If the photographer is not there at that time then what I will do is draw a very extensive accurate picture of the optic nerve where the hemorrhage is as well?

Answer:  Well then that would be your extended ophthalmoscopy.

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Question:  And I could bill for that?

Answer:  Right because extended ophthalmoscopy does not require photo to be taken.

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Question:  Right but I am doing it in lieu of a photo.

Answer:  Right so you do meet the requirement.

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Question:  May I ask another question or do I have to be dropped?

Answer:  Yes.

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Question:  In regards to acute photopsias and I am doing a scleral depressed exam.  Generally if I do a scleral depressed exam I do not bill an ophthalmoscopy unless I see something in the far periphery that I am unable to photograph?

Answer:  Okay.

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Question:  If I do a scleral depressed exam for photopsias and I do not see anything then I do not bill an extensive ophthalmoscopy because then there is nothing for me to draw?

Answer:  Well extended ophthalmoscopy can be billed when it is done if you perform it and do not find anything what you would do is document that you did not find anything but document what you did as well because you still performed the service.  Your diagnosis code would most likely be a sign or symptom rather than a definitive diagnosis though and that is where you might come into a problem.

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Question: So is it accurate and appropriate when I do a scleral depressed exam for photopsias to bill an ophthalmoscopy?

Answer:  If the service is done you can bill it. I think you probably want to talk with your biller and find out what covered diagnosis codes you can use with extended ophthalmoscopy and make sure that one still will work for the exam that you did if you did not find anything.

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Question:  My question is related to HRTs and OCTs.  What are the correct coding bundles with those tests as it relates to other diagnostic services visual fields etc

Answer:  Well I think what you are asking is if you can only bill them within so much time of each other.

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Comments:  Correct.

Answer:  Okay there is nothing now I mean most practices that I have talked to that do have an HRT or OCT type machine have been doing them on the same day as their visual fields for the majority of their patients so they are coming in having the field having the HRT and then seeing the doctor and there is no problem billing those out on the same day or any limitations to doing that.

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See issue PDF for slide pics associated with this teleconference.

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