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Young Ophthalmologists
Who Fits the Bill? 12 Questions to Ask When Filling a Billing Vacancy

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Ophthalmologists rely on the knowledge and skills of their billing staff to help keep the office compliant and assist in appropriately maximizing reimbursement. When recruiting billing staff, some practices look for applicants with little or no billing experience — if they are then trained in-house, they won’t bring any noncompliant ideas to the practice. However, if you would prefer someone who can hit the ground running, here are 12 questions to test an applicant’s coding savvy:

  1. What is the difference between a diagnosis and a procedure? Give an example of each. Both a diagnosis (ICD-9) code and procedure (CPT) code are required when filing a claim. The ICD-9 code 365XX glaucoma, for instance, correlates with the CPT code 92083 visual field.
  2. What documentation do you need when coding a consultation? You need both a written request for the consult from an appropriate referring source (a provider with a UPIN number) and a letter to the referring source specifying outcome and any test or surgery recommended.
  3. What are the differences between the Evaluation & Management codes and the Eye Codes for office visits? E&M (99XXX) documentation is nationally recognized by all payers. Eye Codes (92XXX) are specific to individual states and payers. Some Medicare carriers have specific Local Medical Review Policies with documentation requirements; others rely on the CPT descriptor.
  4. Is CPT code 99213 paid the same by all payers? No. Payers calculate relative value units differently and incorporate other factors. Therefore, fee schedules vary per payer and within subplans of a single payer.
  5. How should unilateral procedures be coded? Unilateral means the procedure is billable per eye when medical necessity exists. CPT code with –50 modifier and/or a two line item with the –RT and –LT modifiers.
  6. What is the full definition of 66982? See CPT descriptor. The key point to remember is that it is not to be used for complications that occur during surgery.
  7. What is bundling? Bundling is generally referenced by the Correct Coding Initiative or black box edits where payers have determined certain sets of codes that are not separately payable when performed during the same session.
  8. What is upcoding? Selecting a higher code value than was actually documented.
  9. Explain one reason why CPT code 76519–RT might be denied payment on the medical explanation of benefits. Payment is usually denied because the ordering physician’s UPIN number is not submitted on the claim form.
  10. Define modifiers –25, –50, –51, –57 and give an example of each.
    • –25 should be attached to the office visit when a minor procedure is performed the same day.
    • –50 is attached to a procedure code when the services are provided bilaterally.
    • –51 is attached to the second through fifth procedure codes when multiple procedures are performed on the patient in the same setting.
    • –57 is attached to the office visit when determination to perform a major surgery is made.
  11. Can a practice have more than one fee schedule? Yes. But you can’t charge your Medicare patients more than your usual and customary fee schedule.
  12. Who is ultimately responsible for code selection? The physician.

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*This article was originally published in the September 2003 issue of EyeNet, a magazine published monthly by the American Academy of Ophthalmology.

About the author: Sue Vicchrilli, COT, OCS, is the coding executive for the American Academy of Ophthalmic Executives.