Ophthalmology and Optometry Coding Alert

Here's how to get paid when insurers don't recognize the new codes

Just because Medicare expects you to dive into the new diagnostic codes Oct. 1 without a grace period doesn't mean other payers will be ready for the change. Prepare to wear multiple hats until everyone arrives on the same page.

Often, non-Medicare payers are not yet current on new CPT and ICD-9 codes on Oct. 1, says Phyllis McClendon, biller with Genesis Eye Care in Charlotte, N.C. Some payers won't update their systems for several months after you are supposed to be using the new codes.

So, for example, from January until April you'll be required to use the new CPT codes with Medicare, but other payers may only accept the old codes, according to consultant Mary LeGrand with Karen Zupko & Associates in Chicago.

"Private carriers may not be using 2005 ICD-9s by Oct. 1," leaving providers to manage two systems, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions in Lakewood, N.J. In particular, workers' compensation programs often take a year or more to get up to speed with CPT codes, LeGrand says.

Strategy: Call all your major payers to find out what they're doing, Cobuzzi says. That way, you'll know which  codes to use for which payer, and for how long.

"If you submit the right codes, you'll get paid on appeal," says Elizabeth Woodcock, director of knowledge management for Physicians Practice Inc. in Glen Burnie, Md. Designate a "follow-up team" to track and appeal these denials. Type up a standard appeal letter for these cases so you won't have to retype it every time.

"In prior years, the AMA said, 'You can start using [new codes] as soon as we release them,' but [providers] had additional leeway until CPT books were published in January," LeGrand says.

Heads-up: CMS and the Centers for Disease Control and Prevention may be releasing new ICD-9 codes in April, in addition to the usual October set. The extra load of ICD-9 codes could come out in January with an April effective date, or in April with a July effective date, LeGrand says.