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Each day, practices spend a significant amount of time performing tests, and it is critical that they get reimbursed for those services. Follow the four tips below to ensure appropriate payment.
Tip 1: Review Your Documentation
When a nonphysician performs a test, a written order is needed. Any test that is delegated (i.e., not performed by the physician) requires a written order, which should specify: 1) the test that is to be performed; 2) right eye, left eye, or both; and 3) medical necessity. This must be documented in the medical record (not on the superbill or charge sheet). Technicians may write the order as dictated by the physician. A physician’s signature is required.
The physician must provide the interpretation and report. There are no published documentation requirements of what exactly the report must say. The interpretation and report can be on the test or in the medical record, or it can be a separate written or dictated page.
Tip 2: Do Not Bill These Tests
The following services are not payable separately from the E&M and Eye codes for office visits. Furthermore, although these services may be components of an office visit, you should not include them as countable elements when determining which level of E&M or Eye code to use. (Please note: This is not a complete list.)
• Accommodation and convergence
• Amsler grid
• Basic sensorimotor evaluation
• Binocular function
• Color vision screening (Ishihara or pseudo-isochromatic test plates)
• Confrontation or gross visual fields
• Dilation of pupils
• Glare testing
• Potential acuity measurement (PAM)
• Schirmer tear test
Tip 3: Check the CCI Edits
CMS developed the National Correct Coding Initiative (CCI) to promote accurate coding methodologies. Under CCI, certain pairs of services should never be billed separately when performed by the same provider on the same patient on the same day, and there are other services that can be billed separately only under certain circumstances. In order to prevent improper payment when incorrect code combinations are reported, CCI publishes two tables: the Column 1/Column 2 Correct Coding Edits table and the Mutually Exclusive Edits table. These tables list pairs of codes. Each pair is known as a “CCI edit” and is labeled with a numerical indicator:
“0” denotes that two codes are mutually exclusive. There are never circumstances in which the codes can both be paid when performed during the same visit on the same eye.
“1” denotes that two codes may be “unbundled.” Do this by appending a modifier to the code in the second column to signal a “distinct procedural service.” Use –25 for a minor procedure; –59 for a major procedure.
Tip 4: Don’t Rely on Common Sense!
Common sense may suggest that a diagnosis is covered, but you should still check Local Coverage Determinations (LCDs). For a list of covered diagnosis codes, refer to your LCDs or the Ophthalmic Coding Coach available at the Academy store (www.aao.org/store). If in doubt, obtain the Advance Beneficiary Notice of Noncoverage (ABN) for Medicare Part B payers.
CCI Edits for Tests
COLUMN 1/COLUMN 2 EDITS TABLE
Column 1 Column 2 Indicator
92018 92020 0
92019 92020 0
92136 99211 1
MUTUALLY EXCLUSIVE EDITS TABLE
Column 1 Column 2 Indicator
92081 92082 0
92081 92083 0
92082 92083 0
92136 76519 0