Primary Care Coding Alert

4 tips add 99173 dollars to your bottom line

You can avoid forfeiting reimbursement for a vision test (99173) with a well exam if you know what payers to report it to, when to report the screening test, and what added documentation you need to include.
 
Faced with denials for 99173 (Screening test of visual acuity, quantitative, bilateral), 99382-99383 (New patient preventive medicine services) and 99392-99393 (Established patient preventive medicine services), many FP coders question if they should separately report a vision screening. "Am I misunderstanding the definition of 99173 when my physician performs the service with a well-child exam?" asks Carmen Nino, office manager for Takashi Yoshida, MD, in Sunnyvale, Calif. Payers keep denying 99173 as a nonpayable code, stating that they consider it a component of the other billed E/M code.

Don't give up, says Victoria S. Jackson, Medical Group Management Association Primary Care Assembly member. Even though you can't do much to change Medicaid programs that bundle 99173 with the well exam, with some added ammunition you can convince managed-care organizations (MCOs) to cover the screening. Here's how:

1. Know Age Restrictions

First, you should know that insurers typically limit 99173 coverage to four preventive medicine service codes: 99382-99383 and 99392-99393. These coverage limitations are based on the American Academy of Pediatrics' (AAP) recommendations that physicians check children aged 3 to 6 for visual acuity, says Peter Broderick, MD, associate director of the University of California, Davis-affiliated family practice residency at Doctors Medical Center in Modesto. So payers created age restrictions that reflect when children should receive vision screening using in-office methods, such as Snellen visual acuity testing.

2. Explain That a Well Exam Doesn't Include 99173

To get the screening paid, you should first educate insurers that CPT allows you to separately report the vision screening with a preventive medicine service.

Send the payer a copy of CPT's:
 
1. 99173's parenthetical notes: "Other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive medicine services)"
 
2. Preventive medicine service introductory notes: "Immunizations and ancillary studies involving laboratory, radiology, other procedures or screening tests identified with a specific CPT code are reported separately."

3. Collect Screening Usage, Cost-Comparison Data

Even if private insurers deny 99173, you should still report the code. Doing so will allow you to gather accurate statistics on how often your FP performs the service. Then, compare how much the screening would cost if you sent all patients to a local ophthalmologist, rather than offering the service in-house.

Take these numbers to your private payers at contract renewal time. "If the HMO/MCO representative sees that covering the service costs them less than paying for ophthalmology-performed screenings and long-term vision problems that may result from not performing the vision screening, you may win 99173 coverage," Jackson says.

4. Reject 'Medicare Bundles the Service'

Also watch out for MCOs that blame Medicare for the 99173 bundle. Although preschool children are rarely Medicare patients, numerous insurers claim that they follow Medicare's policies. But CMS does not designate 99173 as a bundled service, says Chip Hart, with the Winooski, Va.-based Physician's Computer Company. "Therefore, for an insurer to claim that it bases its 99173 bundle on Medicare's policies is a bit disingenuous."

Explain to the payer that Medicare does not bundle the screening. The National Physician Fee Schedule instead identifies the screening test as a noncovered service.