Ophthalmology and Optometry Coding Alert

To avoid fraud and receive appropriate reimbursement, ophthalmology coders must know when they can bill for technician services and when the services are incident to the physician. A technician works for an ophthalmologist in three main areas:

1. screening a patient for the physician,
2. performing a testing service, and
3. performing preoperative checks.

In this article, we will discuss whether these services are billable, and how to code them when they are.

Screening the patient for the physician is not separately billable from the service the physician provides. Before the ophthalmologist sees the patient, the technician obtains a medical and ocular history (interim if an established patient), and a chief complaint, and performs various screening procedures such as testing visual acuity, confrontational visual field, ocular motility, pupillary reaction, intraocular pressure and, in some practices, a slit-lamp examination. After the slit lamp has been performed by either the technician or physician, the technician dilates the patient, when appropriate. These screening procedures are not separately billable. The physician will see the patient, and the physicians code whether an evaluation and management (E/M) code or an eye code (92002-92014) will encompass the work done by the technician. This is because the technicians services fall under the Medicare incident to rule, which states that services performed by individuals employed by the physician are to be handled as incident to the physicians service and included in the physicians billing.

The technician is employed by the physician to provide assistance, explains Raequell Duran, president of Practice Solutions, an ophthalmology coding and compliance consulting company based in Santa Barbara, Calif. The physician is the one who renders the service. The technician documents the patients chief complaint, acquires a history and performs testing services; the physician completes the service. All of the work performed by the technician becomes billable work for the physician.

Technicians Are Considered Incident To

The ophthalmic technicians used by ophthalmologists differ from the nurse assistants who help in obstetricians offices because, for example, technicians are not licensed by the state, notes Lise Roberts, vice president of Health Care Compliance Strategies, a consulting and compliance consulting company based in Jericho, N.Y. Ophthalmic technicians may be certified through the joint Commission on Allied Health Professionals Organization, but they cannot receive Medicare or Medicaid provider numbers, universal provider identification numbers (UPINs) or provider identification numbers (PINs) for the purpose of billing because they are not licensed. This is true nationwide, Roberts says. All services of ophthalmic technicians must therefore be incident to a physicians service to count toward a physicians coding. Services of allied health professionals such as nurse practitioners (NPs) and physician assistants (PAs), who are licensed by the state to practice within the scope stated in their licensure, can be billed to Medicare or Medicaid using the practices provider number and the pin of the NP or PA.

Note: The same supervision rules are required by commercial payers as well as Medicare.

When the physician employs auxiliary personnel to assist him or her in rendering services to patients and includes the charges for those services in his or her own bills, the services of such personnel are considered incident to the physicians service, Duran says. This is true, however, only if there is a physicians service rendered to which the services of such personnel are an incidental part and there is direct personal supervision by the physician.

Technician Visits 99211 and Other Services

Some other procedures, usually done without the physician seeing the patient, can also be billed as incident to. Code 99211 (office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician) states that the presence of a physician is not required. In ophthalmology, this code is often referred to as a tech check or tech visit. Code 99211 should not be billed to reflect the work of the technician who is performing a testing service on a patient in for an office visit, Duran says.When the testing service is billed under the physicians provider number, the work the technician provided is considered incident to the physician service that is being billed. Use of an additional code to bill the work done by the technician would be double-billing and considered fraudulent. Reimbursement for the technicians work doing the test is included in the payment of the testing service.

Although screening the patient prior to the physicians providing an office visit cannot be billed, other incident to services can. Services are also considered incident to when they are furnished during a course of treatment in which the physician performs the initial service and subsequent services at a frequency that reflects his or her active participation in and management of the course of treatment. However, the direct personal supervision requirement must still be met with respect to every nonphysician service.

Note that direct personal supervision requires the physician to be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing the services, according go the Medicare Carriers Manual (2050.2).

Some of the procedures technicians perform that can be billed as incident to include 92250 (fundus photography with interpretation and report), 92081-92083 (visual field examination, unilateral or bilateral, with interpretation and report), 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report), 76511 (ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification), 76512 (ophthalmic ultrasound, echography, diagnostic; contact B-scan [with or without simultaneous A-scan]), 76513 (ophthalmic ultrasound, echography, diagnostic; anterior segment ultrasound, immersion [water bath] B-scan or high resolution biomicroscopy), 76516 (ophthalmic biometry by ultrasound echography, A-scan) and 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation).

Medicare says that we cant do any of these tests without the doctor being on the premises, says Kitty Timmes, COMT, office manager for Joseph J. Timmes Jr., MD, FACS, a retinologist practicing in Annandale, Va. These are all scheduled tests. The doctor sees the patient and then orders the tests for another day.

Timmes notes, however, that some tests, such as fundus photography and fluorescein angiography, can be done on the same day if the physician feels it is urgent.

When the technician performs a testing service, the physician can charge a fee because he or she provided the initial service, ordered the test and remains involved with the patients treatment. The technician provides the testing service, and the physician bills the appropriate testing code under his or her identification number. In this type of encounter, there isnt an additional office visit service to be billed. But what if the technician performs a visual field and also measures the patients visual acuity and intraocular pressure? Is that a billable visit? Not necessarily. There must always be a medically necessary reason for a visit or service. The reason for acquiring the vision and pressure measurements may be because its the standard of practice to record those findings for every patient who is seen. But it is not a reason for Medicare to reimburse for an office visit. If the patients pressure was out of control at the last visit and the physician changed the medication regimen, ordered the visual field and ordered a tech check of the pressures to follow on another date, the tech work involved in the brief history on medication change and pressure check could be billed using 99211 in addition to the visual field code.

What is Physician Supervision?

There has been confusion about physician supervision due to a Medicare rule that was never implemented, Duran explains. In the final rules for 1998 (published in October 1997) the Federal Register defined the categories of supervision as general, direct and personal. In addition, all diagnostic service CPT codes were assigned to one of the categories of supervision. The visual field codes (92081-92083) were assigned general supervision. General supervision meant that the physician was responsible for the upkeep of the equipment and training of personnel, but was not required to be on-site. Its very important to remember, Duran notes, that these supervision definitions were never implemented. HCFA sent a memo to the regional HCFA offices advising them not to implement the final rule published in the Federal Register in October 1997.

In addition, the regional offices were instructed that until further notice they should rely on the old language and requirements for testing service supervision. Because of other, more pressing issues that HCFA was busy resolving, no further notice was ever issued to the regional offices and the final rule has never been implemented. All ophthalmological testing services still require direct physician supervision, which means a physician of the group must be on the premises and immediately available during the test.

Distinguish Between Technician and Technical

Be careful not to confuse the terminology technical component with the technician who performs the testing service. Due to the language of the two modifiers that make up the global testing service, -TC (technical component) and modifier -26 (professional component), people sometimes misinterpret the language, thinking that -TC equals work done by a technician, and -26 equals work done by the physician. This is not true. The technical component refers to conducting the test itself regardless of who conducts it, and it includes the visual field printout, angiogram, photos, etc. The professional component refers to the physician interpretation of the test results.

When a technician performs the technical component, he or she is providing that service incident to the physician who is going to bill for the service. This means (in a sense) that the technician is acting on behalf of the physician, Duran says. The technician is not able to perform a service and bill it if the service is not incident to the physician. All work performed by the technician is incident to the physician, so there is no time when you can bill a service (to Medicare) performed by a technician without meeting the requirements of incident to physician supervision. Incident to services require that the physician has initiated care of the patient and that the direct personal supervision requirements are met. The direct personal supervision requirements state that a physician of the group practice is on-site and immediately available to assist.

Preoperative Exams

Ophthalmologists often feel they should see patients prior to surgery to check on medical problems. Sometimes the ophthalmologist sees the patient, and sometimes the technician does. What is the correct way to bill for these encounters?

If the technician performs this check, the only code you can use is 99211, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a coding and compliance consulting company based in Spring Lake, N.J. A technician check is not billable at all as a pre-op unless they use 99211 and the visit occurs more than one day prior to the surgery, she explains. If, however, the ophthalmologist does the preoperative examination more than one day prior to the surgery, you could bill another E/M code (99212-99215).

Some ophthalmologists think that a technician can bill for any level visit as long as it is under the supervision of a physician, but that is wrong. Only allied healthcare professions who are licensed by the state can bill this way, and then only for those services included in the scope of practice established for that type of license, Roberts notes.

Some practices never use 99211 for the technician but you can in some circumstances, providing there is a complaint. For any office visit to be covered in the Medicare program, there must be a complaint of a sign and/or symptom from the patient, a known condition, or a physician-recommended return.

However, in the example of a cataract patient returning for an A-scan, the physician has already diagnosed the problem, the patient is scheduled for surgery, and any non-testing service provided in the interim is technically preoperative and not separately billable. The A-scan can be billed, of course.