Nothing is as constant as change. That phrase was not written to describe the rules and regulations of documentation and coding, but it certainly fits. Ask any of the ophthalmologists of every subspecialty who attended CODEquest Coding College in 2011. The following are a few of the learning gaps in their coding knowledge identified in course evaluations:
- Modifier -58 is not just for planned staged procedures. Detail: Modifier -58 Staged or related procedure or service, by same physician or other qualified health care professional, can also be used when a greater procedure is performed within the global period of a lesser procedure. When an injection is given in the office during the global period of another procedure, it is appropriate to append modifier -58 to the injection code. Payment is 100 percent of the allowable, and a new global period is started.
- If the procedure/test or exam you are performing on a Medicare Part B patient is not a covered benefit, a claim does not need to be submitted. Detail: If the patient insists, append modifier –GY to the CPT code. An Advance Beneficiary Notice (ABN) is not needed in this situation.
- Physicians can and should be paid for testing services performed during the global period of a surgery, whether the test was related or not. Is your billing staff submitting the tests for payment?
- Without documenting at least four elements to the history of the present illness, the overall exam won’t qualify for a level higher than 99203.
- There is no official audit form for the eye codes (92002, 92012, 92004, and 92014).
- Correct Coding Initiative (CCI) edits should be checked when performing multiple procedures in the same operative session. Detail: Every single code combination has to be checked. Failure to do this results in loss of overall payment. CCI edits may be viewed from www.aao.org/coding. They can also be accessed in the Ophthalmic Coding Coach.
- Following physician signature guidelines is critical. A physician signature is the first thing auditors look for. If it’s not there or is illegible, payment must be refunded. Detail: Signature guidelines specifics can be found under Coding Tools on the AAOE website.
- Participation in the Physician Quality Reporting System and e-prescribing incentive programs is worthwhile — and may be easier than you think. Detail: The step-by-step process for either claims or registry reporting can be found at www.aao.org/pqri or www.aao.org/e-rx.
- Obtain an ABN on Medicare patients for all oculoplastic procedures. Details: The ABN is the payment safety net if the payer determines that the oculoplastic procedure, post payment, is cosmetic rather than functional. Without having an ABN on file, and appending modifier –GA to the surgical code, physicians are prohibited from billing the patient.
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About the author: This article was adapted from an article that appeared in the December 2011 issue of Coding Bulletin. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS, a regular speaker at the Academy’s YO Program during the Annual Meeting. She is scheduled as a coding presenter at the 2012 YO Program in Chicago.