Ophthalmology and Optometry Coding Alert

The Medicare Fee Schedule for 2002, with its reduced conversion factor, will lower payments to all physicians, including ophthalmologists, but an increase in some practice expense relative value units (RVUs) will benefit ophthalmologists.
 
First, the bad news: the conversion factor is to be decreased to $36.20 from $38.26, which will result in lower fees for all codes and all specialties. According to physician groups, including the American Academy of Ophthalmology (AAO), the reduction is based on erroneous data and a poorly designed formula. The AAO is lobbying Congress to fix the problem.
 
"The update is based on poor policy," says William Rich, MD, secretary for federal affairs for the AAO. "Physicians are being needlessly penalized, after enduring cuts for 10 years."

But there is good news, too. Practice expense RVUs will raise payments to ophthalmology practices by 5 percent overall. This includes increased payments for glaucoma surgery (66170, fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery), revision of iris (66761, iridotomy/iridectomy by laser surgery [e.g., for glaucoma] [one or more sessions]) and treatment of retinal lesions (67218, destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; radiation by implantation of source [includes removal of source]).
 
"This may be good news, but keep in mind that reimbursement averages are based on new RVUs multiplied by the 2001 conversion factor," says Ramona Cosme, president of Ramco Medical Billing, an ophthalmology coding and billing consultancy based in Edison, N.J. "Hopefully, they'll stick with the 2001 conversion factor until they can come up with a new formula." Physician groups are asking CMS to keep the 2001 conversion factor until a better formula is worked out.

Other good news: the global period for 65855 (trabeculoplasty by laser surgery, one or more sessions [defined treatment series]) has been decreased from 90 days to 10 days effective January 1, 2002. This means that you can bill for follow-up care provided more than 10 days after surgery, instead of waiting three months. It also means that if a repeat treatment or session is required it can be billed 11 days after the initial surgery. 
 
Local carriers may respond to the change with their own revised frequency guidelines, however. "Everything is based on medical necessity," Cosme says.
 
Typically, ophthalmologists don't repeat the laser trabeculoplasty. But if the desired result is not obtained, the procedure may have to be performed again. Although rare, the second treatment would be paid for if performed outside of the postoperative period. "One or more sessions" usually applies to the postoperative period of a procedure.
 
For example, the ophthalmologist performs the initial procedure on Jan. 2. Anything until Jan. 13 would be included. On or after Jan. 13, the procedure can be performed and billed again, which would start another 10-day global period.

Finally, the new fee schedule includes a glaucoma screening benefit for high-risk groups. CMS included diabetics, patients with a family history of glaucoma, and African-Americans 50 and older as high-risk.
 
The glaucoma-screening service includes a dilated eye examination with intraocular pressure and direct ophthalmoscopy or slit lamp examination. Use G0117 when performed by an optometrist or ophthalmologist or G0118 when performed under the direct supervision of an optometrist or ophthalmologist. Use diagnosis code V80.1 (special screening for neurological, eye, and ear diseases; glaucoma).