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IN, carrier which conducts the National Correct Coding Initiative (CCI) updates under contract to HCFA, has just rescinded these editsretroactive to January 1998.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.)

The CCI was created by HCFA four years ago to deal with what it viewed as double payments; since HCFA says some services are already included in a procedure, bundled services should not be billed separately. AdminaStar submits its proposed bundling edits to the American Medical Association (AMA) for comment on a quarterly basis.

The deletion of the 12 correct coding edits (92002,
92012, 92004, 92014 with component codes 92020, 92060, and 92100) takes place with the regularly scheduled update to CCI, version 5.2, which is being implemented this month (July 1) by Medicare Part B carriers.

AdminaStars decision to unbundle the codes was based partly on comments from the American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Ophthalmic Administrators (ASOA), two groups which are based out of the same office in Fairfax, VA. These comments were given high priority, says AdminaStars Dietz.

In a memorandum explaining why the eye exam
codes should be unbundled from the three specialized test codes, Pam Johnson, ASCRS manager of regulatory affairs, notes that sensorimotor evaluation, gonioscopy, and serial tonometry should not have a separate procedure designation. The basis for the bundles is that these procedures are defined as separate procedures in the CPT, says Johnson. However, these procedures are rarely done independently of eye exams or other procedures, so they should not be designated as separate procedures.

For example, if a patient who needed serial tonometry came in for an eye exam, under Medicare logic, in order for the doctor to be paid for serial tonometry he would have had to schedule a separate appointment and make the patient
come back.

Sensorimotor Evaluation: 92060

While the sensorimotor evaluation can be performed at a different session, the test isnt incorporated into the work values of either the E/M services exams or the eye exams, says Johnson. It is intensive, requires extra skill, and takes a significant amount of time over and above that used in performing the ocular examination.

Johnson notes that to make a patient come back to the office for a sensorimotor exam can be extremely inconvenient for the patient. If the sensorimotor exam must be scheduled for the same day as the office visit because, for example, the patient lives far away from the office, then it is grossly unfair to penalize the provider for this, she says.

The sensorimotor evaluation measures the cardinal positions (the points that indicate focusing activity) of gaze when there is a complicated strabismus, Johnson explains. The deviation must be measured with prisms, she says. This is very time consuming and can easily add another 30 to 60 minutes or more to the examination. Other tests may need to be conducted as well, such as Worth 4-dot test (measuring the ability to perceive images simultaneously using colored dots), Lancaster red-green (patient wears one green and one red lens and tries to superimpose a green streak onto a red streak on a grid), and stereopsis evaluation (how two similar images are blended visually).

Finally, the sensorimotor exam requires an interpretation and report, which is extra work, Johnson notes.

Gonioscopy: 92020

Gonioscopy is not included in the definition of the requirements of an eye examination, says Johnson. Gonioscopy is a test for glaucoma, done to determine whether the angle between the anterior surface of the iris and the cornea is open, narrowing, or closed. Someone with narrow angles is at risk for narrow-angle glaucoma. If there are narrow anterior chamber angles, then the test should be performed. It is not, however, an element of an eye exam; its not included as an element in the 1997 E/M services guidelines either.

Johnson acknowledges that gonioscopy could be bundled into the eye exam codes which have much looser requirements than E/M codes. However, Medicare is unbundling gonioscopy as well as the other two tests from the eye exam codes.

Like the other two tests, gonioscopy is not typically done on a separate day; it is most often done on the same day as the exam. Asking patients to come back for it (in order to get paid if it is a bundled code) wouldnt make sense.

Serial Tonometry: 92100

Serial tonometry is a very specialized test normally performed only by glaucoma subspecialists or at academic medical centers, explains Johnson. It is never a routine component of an eye examination and, in fact, not even incidental to it. Rather, the test is done when intraocular pressure (IOP) is found to be elevated during an exam, or when IOP is being treated or monitored for progressive disease.

Note: This is not the same as the one-time pressure check done with routine eye exams. It involves several pressure determinations over several hours.

The exam is not typically performed unless there are other abnormal findings. It should not be a separate procedure, says Johnson.

Like the sensorimotor evaluation, serial tonometry requires an interpretation and report, Johnson notes. This indicates that as a diagnostic test, it requires extra work effort and is not included in the exam. Therefore, serial tonometry should be reimbursed additionally, even if performed on the same day as an appropriate office visit or consultation.

This unbundling is a victory for ophthalmologists. While they had been able to bill for these three tests in addition to office visits on the same day, they could only do so if they used the E/M services codes. And that also was in jeopardy, because of plans to bundle the three codes with the E/M services codes as well. Now that all of this bundling is history, you can bill for gonioscopy, serial tonometry, and sensorimotor exams in addition to either the eye exam codes or the E/M services codes.

When AdminaStar first proposed these bundle edits
to the AMA in March, the American Academy of Ophthalmologyas well as ASCRS and ASOAsubmitted its objections. E/M codes and eye codes were never meant to include the physician work involved in these other diagnostic services, as Michael X. Repka, MD, chair of the AAOs Health Policy Committee, said in objecting to the edits. Therefore, it is inappropriate to bundle such service elements.