Ophthalmology and Optometry Coding Alert

These and other questions were answered recently by one payer.

Coding for eye care specialists can present challenges and questions almost every day, and it’s always nice to have direction straight from payers. Fortunately, Medicare Administrative Contractor (MAC) reps are able to provide that guidance from time to time, and they did so recently during the Nov. 29 NGS Medicare webinar “Vision Services.”

During the call, NGS reps answered questions from eye care practices. Read on for the scoop.

Question 1: Any Chance Medicare Will Cover Glaucoma Screenings for Average Risk Patients?

That does not appear to be on the horizon, said NGS’ Gail O’Leary during the call. “I haven’t seen anything come on yet,” she said. CMS is always adding to the services and options offered, so if you’re hoping for coverage in average risk patients, you could submit a National Coverage Determination request, she said. “They may or may not create an NCD for it …but I’m not aware of anything coming out on that topic offhand.”

What Medicare will cover is an annual glaucoma screening for beneficiaries in at least one of the following high-risk groups:

• Those with diabetes
• Patients with a family history of glaucoma
• African-Americans aged 50 and older
• Hispanics aged 65 and above

“Medical record documentation must show that the patient is a member of one of the high-risk groups,” O’Leary said.

“The covered glaucoma screening includes a dilated eye exam with an intraocular pressure measurement and either direct ophthalmoscopy examination or a slit lamp bio microscopic examination,” she added. The documentation must also show that you performed the covered screening services, and you should include the diagnosis code Z13.5 (Encounter for screening for eye and ear disorders) on your claim. “Keep in mind additional ICD-10 codes might apply,” she said. You’ll report one of the following codes for the service, depending on whether the physician provided the service or merely supervised it:

• G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist)
• G0118 (Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist)

“For the beneficiary, copayment, coinsurance, and deductible do apply for this service, unlike a lot of the other preventive service benefits that CMS offers,” O’Leary added.

Keep in mind: It’s important to remember that this is a screening. Many Medicare recipients will inquire about having this service performed when they have already been diagnosed with some form of glaucoma. Once a glaucoma diagnosis has been established, medical examinations are warranted and the patient no longer qualifies for a screening.

Question 2: What Documentation Does Medicare Require to Support an Interpretation and Report Claim?

Answer: “We don’t have a one size fits all scenario or expectation for documentation,” O’Leary said. “It’s whatever the physician feels is pertinent and important to indicate in that medical record.”

Therefore, you should relay this information to your ophthalmologists and optometrists and defer to them in terms of the specifics of what should be on the documentation.

Question 3: Is There A Way to Report 92250 and 92134 Together?

Answer: The National Correct Coding Initiative (NCCI) does bundle 92134 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina) into 92250 (Fundus photography with interpretation and report), but the modifier indicator on the bundle is “1.”

“If you see a modifier of ‘1’ in there, there may be times when one code is separate and distinct from the other,” said NGS’ Michelle Poulos. “You must be able to show the specific reasons why you’re using the modifier rather than bundling them together.” If you use a modifier, such as 59 (Distinct procedural service) to separate the edits, make sure the reasons for using the modifier are in the medical record, Poulos said. For instance, if the physician addresses two different eyes, that could be a reason to separate the services, but that’s not the only reason.

Remember: Medicare defines both 92134 and 92250 as bilateral codes. Proceed with extreme caution when attempting to bill both 92134 and 92250 on the same date of service, and make sure that your documentation is rock solid before appending a 59 modifier.

Question 4: Should We Send A Refraction Charge to Medicare Even If It’s Not Covered?

Answer: The answer comes down to how you choose to report things in your practice, Poulos said. “The beneficiary may want to see it on the billing and may want to see that it’s denied,” she said. “They may want that denial for other insurers.” In that instance, you could send it in and you could also use the voluntary advance beneficiary notice (ABN) just to inform them it’s something not covered by Medicare.

Keep in mind: An ABN is voluntary for items that are statutorily excluded (never covered by Medicare, such as refraction) or do not meet the definition of a Medicare benefit. But because some Medicare patients don’t know the refraction is not a benefit, the ABN may be a good idea to help explain it. If they sign the ABN, it spells out in detail that refraction is not a benefit and that they will be responsible for the charge if they choose for the doctor to perform refraction.