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November/December 2011

Savvy Coder: Coding & Reimbursement
What Your Colleagues Learned in 2011
By Sue Vicchrilli, COT, OCS, Academy Coding Executive
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(PDF 81 KB)

Nothing is as constant as change. Although that phrase was not written to describe the never-ending evolution of rules and regulations for documentation and coding, it certainly fits; ask any of the ophthalmologists who attended CODEquest Ophthalmic Coding College in 2011.

Six Lessons Learned

Here are some lessons learned, as identified in course evaluations.

CCI edits. Feedback: “Correct Coding Initiative edits should be checked when performing multiple procedures in the same operative session.” Explanation: Every single code combination has to be checked. Failing to do this results in a lower overall payment. CCI edits are at (select “Coding Tools”); they also are listed in the Ophthalmic Coding Coach.

Claims and registry reporting. Feedback: “Participating in the Physician Quality Reporting System and e-prescribing appears easier than I thought.” Explanation: The step-by-step process for claims and registry reporting can be found at and, respectively.

Medicare claims. Feedback: “If the procedure/test or exam you are performing on a Medicare Part B patient is not a covered benefit, a claim does not need to be submitted.” Explanation: If the patient insists, append modifier –GY to the CPT code. An Advance Beneficiary Notice (ABN) is not needed in this situation.

Medicare and oculoplastics. Feedback: “I need an ABN on Medicare patients for all oculoplastic procedures.” Explanation: The ABN is the payment safety net if the payer determines, after payment, that the oculoplastic procedure was cosmetic rather than functional. Without having an ABN on file and appending the modifier –GA to the surgical code, physicians are prohibited from billing the patient.

Modifier –58. Feedback: “Modifier –58 is not just for planned staged procedures.” Explanation: Modifier –58 Staged or related procedure or service by same physician during the postoperative period also can be used when a greater procedure is performed within the global period of a lesser procedure. For instance, when an injection is given in the office during the global period of another procedure, it is appropriate to append modifier –58 to the injection code. Payment is 100 percent of the allowable, and a new global period is started.

Physician signature guidelines. Feedback: “I need to follow physician signature guidelines. A physician signature is the first thing auditors look for. If it’s not there, or if it’s illegible, payment will need to be refunded.” Explanation: Signature guidelines specifics can be found under “Coding Tools” at


Three Quick Tips

Audits. “There is no official audit form for the eye codes” (92002, 92004, 92012 and 92014).

Documentation of history. “Without documentation of at least four elements in the history of the present illness, the overall exam won’t qualify for a level higher than 99203.”

Payment for testing services. “I learned that I can and should be paid for testing services performed during the global period of a surgery, whether the test was related or not. Our billing staff has never submitted the tests for payment.”


CODEquest 2012: Introducing ICD-10

Make the transition to ICD-10 with CODEquest Ophthalmic Coding College. In preparation for the biggest change in coding in more than 20 years, attend courses and earn CME, JCAHPO and AAPC credit. This new CODEquest course will teach ophthalmic professionals how to implement ICD-10 smoothly and successfully.

For a list of CODEquest courses for 2012, go to


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