Ophthalmology and Optometry Coding Alert

Their services can boost the E/M level -  if they're following the incident-to rules

Although technicians are worth their weight in gold in any ophthalmology practice, reporting their services can sometimes cause headaches for coders. But coding technicians' services - and recapturing potentially lost revenue - is as easy as knowing a few Medicare rules. 
 
Let the answers to these frequently asked questions guide you toward more effective incident-to coding.

Question: Our tech often performs visual acuity and intraocular pressure tests during patient exams. Since the ophthalmologist is not performing those tests, can he include them in the exam level list to determine an E/M level?

Answer: Yes - as long as your tech is meeting the "incident-to" requirements. The technician must be an employee of the physician practice, and the physician must either be involved in the service that day or have initiated care of the patient, made a plan of care and remained involved in the patient's care.
 
The technician must also meet the supervision requirements. The Medicare Carriers Manual limits incident-to coverage to "situations in which there is direct personal physician supervision." "The physician does need to be in the office" for you to be able to code for incident-to services, says Christina Hollis, OCS, coder and surgery scheduler at Pediatric Ophthalmology Associates in Columbus, Ohio. The physician must be present in the office suite and immediately available to provide assistance and direction, Hollis says.
 
Exception: In a group practice in which all of the physicians bill under the same tax ID, "as long as one of the other doctors is physically in the office, then you can bill for [incident-to services]," Hollis says.
 
Example: The tech performs visual acuity and IOP tests on an established patient. The ophthalmologist tests visual fields and ocular motility, and performs slit lamp exams of the patient's corneas, lenses and anterior chambers. The ophthalmologist made medical decisions of low complexity.
 
Since the ophthalmologist and the tech performed a total of seven tests, the exam portion of the E/M service qualifies as "expanded problem-focused." That and the low-complexity MDM qualify the service for 99213 (Office or other outpatient visit for the evaluation and management of an established patient...).
 
Watch out: Local coverage determinations may differ in the number of tests required to reach a certain E/M or eye code (92002-92014) level. Check your LCD for specific requirements.
 
Hidden trap: Don't assume that the tech's write-up of the history of present illness (HPI) will help boost your E/M level. According to Medicare E/M coding guidelines, the physician or NPP reporting the service must obtain the HPI. If the tech takes the HPI, the physician or NPP must clearly show agreement and review of the HPI as documented by the tech. The provider can do this with a statement such as "HPI reviewed and agreed with," or "HPI reviewed and changes or additions as noted." The provider must then sign the HPI statement.

Question: If the ophthalmologist doesn't see the patient on the day that the technician performs a service, is it still incident-to?

Answer: The physician does not have to render a professional service on the same day for the technician's service to count as incident-to, Hollis says.
 
As long as the technician renders his services "during a course of treatment in which the physician performs an initial service and subsequent services which reflect his active participation in and management of the course of treatment," the services are incident-to.
To meet the supervision requirements for incident-to billing, however, the ophthalmologist must be present in the office suite and immediately available, whether or not he sees the patient that day.

Question: If fundus photography only requires general supervision, can we report the technician's services even if the ophthalmologist is not in the office?

Answer: Yes. Since diagnostic tests have their own set of rules, they are not subject to the incident-to rules, says Glenda McDonough, CPC, coder for Sedalia Eye Associates in Sedalia, Mo. You would code these tests under the physician's name and UPIN, but not as an incident-to service.
 
What to do: Look for the requirements for supervision in column "Z" of the Physician Fee Schedule Database ("Level of Physician Supervision"). A "1" in that column means, according to Medicare, that it "must be performed under the general supervision of a physician." The physician maintains overall direction and control of the procedure - but his presence is not required. In other words, the physician must order the diagnostic test but need not be in the office when it's performed,  McDonough says. "Within minutes, we have to be able to be in touch with him, but he does not have to be in the building," she says.
 
These diagnostic ophthalmological tests have a general supervision requirement: