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February 2009

 
Savvy Coder: Coding & Reimbursement
Here’s What You Need to Know About This Year’s CPT Changes
By Sue Vicchrilli, COT, OCS, Academy Coding Executive, and Michael X. Repka, MD, Academy Secretary for Federal Affairs
 
 

Is your practice up-to-date with the latest CPT changes? During an economic slowdown, it becomes more important than ever that you bill accurately. Here’s what every office should be aware of for 2009.

CPT Category I Codes

Category I codes are updated annually with any changes coming into effect on Jan. 1. Within the Eye and Ocular Adnexa section, you should note the following changes to the Cornea listings.

First, the preamble to the keratoplasty segment now reads as follows: Corneal transplant includes use of fresh or preserved grafts. The preparation of donor material is included for penetrating or anterior lamellar keratoplasty, but reported separately for endothelial keratoplasty. Do not report 92025 in conjunction with 65710–65757. Topography was used for valuation of these corneal graft surgeries. (Keratoplasty excludes refractive keratoplasty procedures, 65760, 65765 and 65767).

Second, there are some new and revised keratoplasty codes. These are listed below, with circle codeindicating a new code and triangle code indicating a revised code. The underlined words indicate text that has been added to the revised codes. (While the CPT uses those two symbols to flag changes, a third symbol—plus1—is used to denote add-on codes. These codes are for work that is always done in conjunction with a primary procedure.)

triangle165710 Keratoplasty (corneal transplant); anterior lamellar

triangle265730 penetrating (except in aphakia or pseudophakia)

circle165756 endothelial

plus1circle265757 Backbench preparation of corneal endothelial allograft prior to transplantation (list separately in addition to code for primary procedure). (Use 65757 in conjunction with 65756.)

Please note that code 65756 has a work value of 16.60. The add-on code 65757 is carrier-priced, so your practice or your local society should discuss this with your carrier’s medical director.

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CPT Category III Codes

Category III codes exist to help the CPT Editorial Panel collect data on emerging technologies, services and procedures. These data are then used to determine whether new Category I codes are needed. Here are the three newest ophthalmic Category III codes.

circle30191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach. This is appropriate when coding for the iStent.

circle40192T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach. This should be used by the ASC for the supply of the ExPress shunt and the AquaFlow drainage device.

circle50198T Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report.

Because the purpose of Category III codes is to track emerging practices, they are updated twice a year, in January and July. Consequently, the Category III listings in the AMA’s CPT book, which is printed just once a year, aren’t always up-to-date. Code 0198T, for instance, appears in the AMA’s online listings of CPT codes but not in its most current book, CPT 2009.

Another difference between Category I and Category III codes is that no relative value units are assigned to Category III codes at a national level, so any payer may develop its own specific coverage and/or payment policy. If a Medicare carrier doesn’t cover a particular Category III code, a patient with that carrier may, if notified, be responsible for payment. You would notify the patient with an Advance Beneficiary Notice of Noncoverage (see below) and you should append modifier –GA to the Category III code on the claim.

For further discussion of Category III codes, including the 10 that are most relevant to ophthalmology, see Savvy Coder in the November/December issue of EyeNet (www.eyenetmagazine.org/archives).

Reimbursement

Fee Schedules. The new conversion factor for Medicare is 36.066, which means increased rates for nearly all ophthalmology services. However, non-Medicare payers typically don’t change their fee schedules until July of each year, so it is not yet known what, if any, changes will be made to their payments.

Deductible. The Medicare Part B deductible remains the same as last year—$135 per Medicare patient.

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New Notice of Noncoverage

Is your practice using the new and improved version of the Advance Beneficiary Notice? This replaces the two former versions of the Advance Beneficiary Notice (ABN-G and ABN-L) as well as the Notice of Exclusion of Medicare Benefits (NEMB).

Extended name. The new notice has a new name—the Advance Beneficiary Notice of Noncoverage—but retains the same, familiar acronym, ABN.

Deadline extension. Your practice has until March 1 to comply, which is an extension of the original Sept. 1, 2008, deadline.

When to use it. The ABN should be used when you believe you may have issues obtaining payment for services rendered to Medicare beneficiaries that are considered to be limited either based on the list of diagnosis codes and/or the frequency of the service(s) being performed.

Three options for patients. The ABN offers patients the following choices:

Option 1: I want the service. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice. I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare. If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.

Option 2: I want the service, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

Option 3: I don’t want the service. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

The ABN form is available at www.aao.org/aaoe. Select “Coding & Reimbursement” and then “Coding Tools.”

OCS Exam Flash Cards

Improve coding competence, boost reimbursement and excel in the Ophthalmic Coding Specialist Exam.

Each set of OCS Exam Flash Cards includes 75 laminated cards, with a question and its answer on each card. The set is bound together with a ring that can be removed so you can rearrange the cards in your preferred order. In addition to helping staff prepare for the OCS Exam, these cards can be pinned at the desk for easy reference when training staff.

OCS Exam Flash Cards (Product #012358) can be ordered online—$25 for members; $33 for members—at www.aao.org/store.

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