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September 2007

Savvy Coder: Coding & Reimbursement
The Claim Game: Five Pitfalls to Avoid
By Sue Vicchrilli, COT, OCS, Academy Coding Executive

Receiving a claim denial notice is one of ophthalmology’s big headaches. With hopes of saving practices the frustration of denied payment, Medicare carrier TrailBlazer Health Enterprises published the top reasons why ophthalmology claims are rejected.

  1. Submitting a duplicate claim/ service. When you haven’t yet received payment for a claim, do you resubmit the claim without investigating why you haven’t been paid? Instead of automatically submitting a duplicate claim, check the claim’s status by contacting Medicare’s interactive voice response system (or its equivalent) before trying again.
  2. Overlooking the details of beneficiary eligibility/benefits. Your claim will be denied if the patient is not covered by Medicare, if the name and/or Medicare number does not match Medicare’s records, or if the patient is enrolled in a Medicare Advantage Plan. What’s the solution? Copy the patient’s Medicare card upon check-in. And of course, those covered by an Advantage plan will carry two types of Medicare cards.
  3. Billing for special testing services inappropriately. Special tests will be denied when performed for a routine exam or screening purposes, and the responsibility of payment will then fall to the patient. You should be aware of both National Coverage Policies and current Local Coverage Determinations. LCDs usually include these components: indications and limitations of coverage and/or medical necessity; documentation guidelines; utilization guidelines (if applicable); and ICD-9-CM codes that support medical necessity.
  4. Forgetting the global period. Medicare recognizes two types of global periods—minor and major. A global package of care consists of all necessary services performed by the physician before, during and after a surgical period. Global periods for minor procedures are those defined as having zero days or 10 days of postop care included in the surgical payment. Major surgeries have a 90-day global period. Many ophthalmologists receive denials for office visits (E&M or Eye Codes) when they have billed during the global period for services that are related to the surgery. Services performed during the global period that are unrelated to the surgery should have modifier –24 appended to the appropriate level of exam. Modifier –24 states that you are billing for an E&M service during the postop period, but it is unrelated to the earlier service.
  5. Not realizing Medicare is the secondary payer. You may be denied payment when another payer is the primary payer. This can happen, for instance, if:
  • The Medicare patient is 65 years or older but is still employed full- or part-time by an employer who has 20 or more full- or part-time employees, or he or she is covered under the policy of a spouse who is still employed.
  • Medicare is the secondary payer to group health plans that cover patients who have end-stage renal disease.
  • If the patient was injured in an accident, an insurer may be the primary payer. In a car crash, for instance, this might be the auto liability insurer.
  • Medicare is secondary to workers’ compensation illness or injuries.
  • The patient is covered by the Department of Labor’s Black Lung Program.
  • Veterans who are entitled to Medicare may choose whether the VA or Medicare will be responsible for payment for services covered by both programs.

Analyze your patient information form. Does it ask the right questions to determine all coverage policies?


CODING ALERT. If you were to treat these corneal burns with a ProKera tissue ring, you should not bill CPT code 65780.


Clarifying Use of CPT code 65780

In recent months, the Academy has received several questions asking about the appropriate coding for CPT code 65780 Amniotic membrane transplantation (AMT). Here is one example:

Question. “Could you please interpret CPT code 65780 ocular surface reconstruction; AMT. The physician in my practice uses this code whenever he uses a ProKera amniotic membrane. For instance, the patient has an alkaline chemical burn of the cornea, we document ICD-9 code 940.2 (alkaline chemical burn of cornea and conjunctival sac), and the physician places a ProKera membrane but doesn’t suture it. Instead he performs temporary closure of the eyelids by suture and codes CPT code 65780, but this would seem to fall under CPT code 67875.”

Answer. For CPT code 65780, Medicare assigns a total of 20.91 relative value units. This total includes 10.43 work RVUs, 10.04 practice expense RVUs and 0.44 malpractice expense RVUs. (For an explanation of the Resource-Based Relative Value Scale that assigns RVU values to CPT codes, see the June Practice Perfect article at

The 10.43 work RVUs are for the work involved in reconstructing the ocular surface, including suturing of the amniotic membrane graft to the cornea to anchor it in position. Placing a ProKera ring involves no dissection of the ocular surface to remove scar tissue, and no suturing or gluing of the tissue. Physician work is similar to that for placement of a therapeutic contact lens (CPT code 92070, fitting of contact lens for treatment of disease, including supply of lens). However, 92070 is not an appropriate code because the reimbursement does not take into account the cost of the ProKera ring.

Temporary closure of the eyelid, CPT code 67875, is assigned a total of 4.51 RVUs in office and 2.34 RVUs in a facility because it is far less difficult and takes less time than 65780.

For the case in question, you should use CPT code 67875, temporary closure of eyelids by suture. There is no separate code or physician payment for placement of the ProKera ring. If done as part of an office visit, it is included as part of the E&M or eye code. However, you should also submit code V2790, amniotic membrane for surgical reconstruction, to get reimbursed for supply of the ProKera tissue ring.

Please note: Inappropriate use of 65780, ocular surface reconstruction; AMT, for placing ProKera or for AMT as an add-on to pterygium surgery, another potential area for abuse, might result in reevaluation of the code. The danger of such a reassessment is that the code could be reduced to a value that is commensurate with fitting of a bandage contact lens.

—David B. Glasser, MD, member of the Academy Health Policy Committee