Ophthalmology and Optometry Coding Alert

Last month, ophthalmologists got some good news from the associations that represent them in Washington, DC.: Medicare has unbundled the eye exam codes (92002, 92012, 92004, 92014) from serial tonometry (92100), gonioscopy (92020), and sensorimotor evaluation (92060). The Health Care Financing Administration (HCFA) announced in April of 1998 that it was bundling these codes for dates of services April 1, 1998, and beyond, as well as retroactively to January 1998. However, AdminaStar Federal, the Indianapolis, IN, carrier which conducts the National Correct Coding Initiative (CCI) updates under contract to HCFA, has just rescinded these editsretroactive to January 1998. Local carriers will reprocess and pay claims that were denied based on these edits.

How To Resubmit Claims

So how should you go about getting paid for any claims that were denied based on the edits since January of 1998? In the past, when changes have been made to the CCI retroactive to the date of the original edits, HCFA has told the carriers to identify the claims where the edits have been applied and reprocess them, explains Linda S. Dietz, ART, CCS, CCS-P, coding specialist for the CCI with AdminaStar. However, this time the carriers may not be able to identify the claims and automatically reprocess them. Providers should identify their denials and resubmit the services to the carriers, Dietz tells OPC. Carriers have been instructed to reprocess claims that are resubmitted.

This means ophthalmology practices will have to go back to January of 1998 and pull any claims that were denied with these codes, and resubmit them to your carrier. Then, you will get paid.

What can you do if you didnt file claims for these codes because you knew they were bundled? You can still get money back, explains Lise Roberts, vice president of Health Care Compliance Strategies of Syosset, NY, and a top ophthalmology coding consultant. Ophthalmology practices need to go through their patient charts and identify cases where one or more of these were done along with an eye exam, says Roberts. The difference is that these diagnostic tests should be filed as original claims rather than a request for payment for a denied service, since they were never billed along with the eye exams in the first place. Original claims can generally be filed up to one year from the date of service with no problems, Roberts explains. However, if the services date back more than one year, which they could since the charge affects claims back to January 1, 1998, then each carrier will need to establish a special way to handle processing so the claims dont get denied for being too old. (Check with your carrier for special instructions on filing in these cases.)
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