Ophthalmology and Optometry Coding Alert
Know Which Eye Test Codes Require You to Retain Images
In some cases, reimbursement could be at risk if you don’t hang on to photos. When it comes to eye care tests, you might think that as long as you submit the right codes, you’re on the road to strong reimbursement levels. But the reality is that some eye care testing services require you to retain images, drawings, and other reports, or you could face denials. That was the word from NGS Medicare during the Part B payer’s Dec. 17 webinar entitled “Vision Services.” To check out the insurer’s tips on reporting these services, read on. Choose From Among 1,000+ Diagnosis Codes for Visual Fields Your eye care specialist is likely to perform visual fields testing frequently, as these services “detect defects in the field of vision, and test the function of the retina, optic nerve, and optic pathways,” said NGS’ Gail O’Leary during the call. Keep in mind that gross visual field testing is considered part of a general ophthalmological service, and shouldn’t be reported separately from those services, she said. Following are the applicable codes for this service: “There are certain symptoms that would suggest visual field testing should be performed,” O’Leary said. Some examples include disorders of the eyelids potentially affecting the visual fields, a documented disorder of the optic nerve or retina, documentation of glaucoma, or a sustained significant eye injury, among many others. “When coding for ICD-10, the diagnosis code you choose must best describe the patient’s condition for which that service was performed,” she said. “There are a total of 1,357 diagnosis codes that would help in the medical necessity determination, but that does not ensure coverage of the service. It must be reasonable and necessary in each specific case, and also must meet the criteria specified in the local coverage determination (LCD).” “The patient’s medical record must contain documentation that fully supports the medical necessity for services included within the LCD,” O’Leary added. “This would include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures performed.” Retain Thorough Documentation for Posterior Segment Imaging Posterior segment imaging is typically performed by ophthalmologists to check for retinal issues, and this category includes fundus photography and extended ophthalmoscopy, she noted. You’ll report extended ophthalmoscopy and fundus photography with the following codes, she said: “Fundus photography involves the use of a retinal camera to document abnormalities of the retina and disease processes affecting the eye in order to follow the progress of such diseases,” O’Leary said. “The test must be used in the medical decision making of the patient.” Fundus photography claims must include a written interpretation, and if the written interpretation is not documented with the photograph, then both the professional and technical components of the code will be denied. These codes are inherently bilateral, and if you perform this unilaterally, you could be subject to a fee reduction, she noted. “A copy of the fundus photographs must be retained in the patient’s medical records, in addition to the interpretation and report,” O’Leary stressed. The documentation in the medical record should clarify whether the pupil was dilated and which dilation drug was used. “Then you’ve got extended ophthalmoscopy, which is the detailed examination of the retina and always includes a true drawing of the retina with interpretation and report,” she said. “It is most frequently performed using an indirect lens, although it may be performed using contact lens biomicrosopy, it may require scleral depression, and is usually performed with the pupil dilated,” O’Leary noted. “It is performed by the physician when a more detailed examination is needed following routine ophthalmoscopy, and it must be used in the medical decision making of the patient.” Extended ophthalmoscopy is indicated when the level of exam requires a complete review of the posterior segment of the eye and documentation is greater than that required of general ophthalmoscopy, she added. However, it’s not covered by Medicare when it’s performed only as a screening service. “Extended ophthalmoscopy has several coverage limitations, which you can read in the LCD. For instance, performing it on a fellow eye without signs/symptoms or new abnormalities will be denied as not medically necessary.” The medical record for extended ophthalmoscopy must include a relevant medical history, physical exam, and pertinent diagnostic test results/procedures to support medical necessity. “Retinal drawings must meet certain specifications as indicated in the LCD,” she added. Frequency guidelines for extended ophthalmoscopy may differ based on the patient’s condition, so check the LCD for that information. In addition, she noted, extended ophthalmoscopy commonly occurs during the global package of ophthalmic surgery, and it’s not separately billable in those situations. Know Your Modifiers for Co-Management A significant number of ophthalmologists perform co-management, which can happen when the surgeon performs a surgical procedure and then another physician, such as a medical ophthalmologist or optometrist, handles the aftercare. “Co-management is a planned transfer of care during the global period from the operating surgeon to another qualified provider when appropriate,” said NGS’ Michele Poulos during the call. “This is indicated only when the operating surgeon is going on leave immediately after surgery, the beneficiary cannot travel a distance to the surgeon’s office for postoperative care, the patient voluntarily wishes to be followed postoperatively by another provider, or the surgery is performed in a remote part of the country.” However, you can’t use co-management if the surgeon follows the patient postoperatively but wants to split the fee with another provider, or the physician demands to manage the postoperative care and refuses to make referrals to providers who won’t agree to split the global surgery payment, she said. The surgeon will use modifier 54 (Surgical care only) and the postoperative management will be billed with modifier 55 (Postoperative management only). “If a transfer of care occurs, the receiving physician cannot bill for any part of the global service until they’ve provided at least one face to face service,” Poulos noted. “In addition, both claims for the surgical service and postoperative care should indicate the date of transfer in item 19 of the claim form or the electronic equivalent.” Documentation required: Both the surgeon and the clinician providing postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record, which must include the date when the care is assumed and must be signed by both physicians. In addition, “The medical record must note the patient was informed of this transfer of care and that the patient gave consent.” For instance, she said, suppose the surgeon performed a cataract surgery (66982, Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation) on Sept. 15, 2020. This surgery has a 90-day global period. The patient stayed at the hospital eight days until Sept. 23, during which time the surgeon administered postoperative care. The doctor will report the surgery with 66982-54 with the date of service of Sept. 15, 2020 and place of service (POS) code 21 (Inpatient hospital). That same physician will also report 66982-55 with POS 21 for eight days of postoperative care, from Sept. 16 to Sept. 23. Then the next physician, who performed the aftercare at their office, will report 66982-55 with the date of service still being the surgical date of Sept. 15. But since postop care was assumed from September 24 through December 14, 2020, they’ll bill for 82 days of postop care, with POS 11 (Office). “The bills must all reflect the surgery date,” Poulos says. “And then separately both physicians must report the range of dates for which you provided postoperative care, which you’d include in the narrative description in item 19 of the claim form or the electronic equivalent,” she said. If one physician performs the preoperative care, the surgery, and all postoperative care (the full global package), the physician will bill the appropriate code with no modifier. “Different physicians within the same group who participate in the care of the patient still will also bill the entire global package,” Poulos noted.
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