Ophthalmology and Optometry Coding Alert

Communicate with your doctors to find the most specific code, or risk losing $695 in reimbursement Your ophthalmologist treats a patient with cataracts. You report CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy) linked to ICD-9 code 366 (Cataract) - but the insurer denies the claim. What happened?

Often, a three-digit diagnosis code does not tell the carrier enough about the patient's illness. When you can make the diagnosis more specific by adding a fourth or fifth digit, experts advise that you should do so.

It's not just Medicare anymore - more payers than ever before are demanding accurate ICD-9 coding. In fact, diagnosis coding
is evolving from a choice to a necessity when filing with some carriers, because they are rejecting claims as "medically unnecessary" at a higher rate than they did a few years ago. And with the Centers for Medicare & Medicaid Services demanding immediate implementation of its new ICD-9 codes from now on, it's plain to see that diagnosis coding isn't getting any less urgent. If you're not taking ICD-9 coding seriously, it's only a matter of time before it affects the practice's bottom line, experts say. Payers Looking at ICD-9 Codes on Claims "A lot of us didn't pay attention to ICD-9 coding in the past because Medicare was the only carrier that cared if you used the [most specific] codes," says Victoria Jackson, owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area.

Tip: Before sending out a claim with a three-digit diagnosis code, you should double-check the code, Jackson says. Three-digit diagnosis codes raise the eyebrows of payers, she says, because there are very few ICD-9 codes that aren't at least four digits. Take the 2-Question Test To ensure accurate ICD-9 reporting, Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont., asks herself two questions before sending out a claim:

1. Do I have a complete code?
2. Do I have the most specific complete code? Why are these things important? If the ICD-9 code is not as complete and specific as carrier rules require, the claim may be rejected for lack of medical necessity, Lamb says. You can check that you have the most complete and specific code when looking up the code in the ICD-9 book - if you know what to look for.

Know When Conditions Require 5-Digit Codes There are certain ICD-9 codes that you must carry out to the fifth digit, so you need to know when a fifth digit is required. One of those codes is 366. In the above example, the ophthalmologist treats a patient with presenile nuclear cataracts. If you link 366 to the [...]