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November/December 2006

Savvy Coder: Coding & Reimbursement

Ready, Set, Go: Prepare Your Practice for 2007
By Sue Vicchrilli, COT, OCS, Academy Coding Executive

Don’t wait until January to implement important coding updates and corrections into your practice. The majority of the work should begin in November, shortly after new guidelines are published in the Federal Register. In addition to updating your fee schedule, what else should you do?

Read your Medicare payer’s Local Coverage Determinations (LCDs), which you can find on its Web site. These are updated regularly, so you should sign up to receive e-mail notification of any updates. Remember that when the payer has published this information on its Web site, it has fulfilled its obligation to inform you. For a complete list of Medicare payer Web sites, visit

Research Your Procedures

For each minor and major surgical procedure that your practice performs, you must know all the following:

Global periods. Medicare publishes the global period for each CPT code. Procedures are considered minor if they have zero or 10 days of global period. An easy way to keep track of this is to designate on the superbill or charge sheet which CPT codes have zero and which have 10 days of postop care. This will make it easy for you to determine when it is appropriate to bill again. Those procedures with 90 days of postop care are determined to be major procedures.

Non-Medicare payers apply a global period of zero, 10 or 15 days to minor procedures and 45 or 90 days to major procedures. When you call the payer for preauthorization or for the new 2007 fee schedule, ask the payer for the global period of those procedures that your practice performs most frequently.

Payment policy. Is the procedure payable per session, per eye, per lid or per lesion? For instance, excision of benign lesions (CPT code 11440) is payable per session, but excision and repair of the eyelid (67961) is payable per eye.

CCI edits. The quarterly CCI edits always include a few changes that affect ophthalmology. When there are two codes that you plan to use together, be sure to check each code against the other. For instance, are visual fields (92081, 92082 and 92083) bundled with optic nerve scan (92135)? By verifying each code mix, you will discover that the two procedures are not bundled when performed on the same date of service.

So what are they bundled with? The visual field exam (92081) is bundled with 92082, 92083 and 99211. The intermediate exam (92082) is bundled with 92081, 92083 and 99211. The extended exam (92083) is bundled with 92081, 92082 and 99211. The optic nerve code (92135) is bundled with 92250 and 99211.

ASC coverage. Is the procedure covered in an ambulatory surgical center? There are about 60 codes in CPT’s Eye and Ocular Adnexa section that are not Medicare-covered benefits when performed in an ASC. In those cases, it is the surgeon rather than the patient who is responsible for payment. The list can be found at

Savvy Coder

What do LCDs say about punctal plugs? Ask yourself the following questions to see how well you know your LCDs. What specific documentation must be made prior to implanting temporary or permanent punctal plugs? What are the retinal coverage diagnosis codes for OCT (CPT code 92135)? How often can optic nerve scans and visual fields be performed for the diagnosis of glaucoma? What specific documentation must be made when removing benign skin lesions in order for Medicare to provide coverage? (Answers may vary depending upon your payer.)