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Young Ophthalmologists
What Every Ophthalmologist Must Know About Coding and Reimbursement, Part 1
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True-or-False Quiz (see the end of this article for answers)

  1. When a claim is denied, simply resubmit until payment is made.
  2. Conducting internal chart audits is mandatory as part of your compliance plan.
  3. All payers must follow rules and regulations according to CMS policies.

Coding is not for amateurs. With impending fee cuts and increase in overhead, practices can’t afford to chronically submit incorrect claims with the hopes that the errors can be corrected the second or third time around. A little known fact is that perpetual resubmission of claims triggers audits. A great New Year’s resolution is to take steps to submit correct claims the first time.

Many sources for coding information are available — the Academy, the American Academy of Ophthalmic Executives, independent consultants and colleagues. Unfortunately, we don’t all sing the same song. Physicians need to decide which voice they are going to listen to.

Where to start? Ophthalmologists tend to see similar types of patients. Focus on the top 10 patient types by diagnosis that you see. If you research documentation requirements that are specific to each payer and routinely conduct internal chart audits to assure that documentation is made, you’ll not only sleep better, you’ll feel confident when the request for records arrives. While conducting internal chart audits is not mandatory, it clearly demonstrates the desire to be compliant and you’ll catch errors before the payer does!

Who are the payers? Unfortunately, there is very little standardization among payers. So before you look at the documented chief complaint, identify the payer. This will help direct your documentation to be specific to the particular payer requirements.

AAOE, the Academy’s practice management arm, has identified four categories of payers:

  1. Medicare Part B. Outside of pediatric practices, ophthalmology patient bases are generally 65 percent Medicare Part B. Remember that if the patient or patient spouse is still working, Medicare Part B becomes a secondary payer.
  2. Medicare Advantage Plans. These Medicare plans are an alternative to traditional Medicare. Patients can opt in or out January through March of each year. These plans seem to follow the rules of the insurance company administering the plan rather than traditional Medicare.
  3. Commercial or non-Medicare payers such as Aetna, Blue Cross Blue Shield, CIGNA, Humana, United Health Care, etc. Each has its own fee schedule, coverage policies, bundling edits, adherence to modifiers, etc. Best practice is to routinely visit their respective websites to keep up-to-date with changes in coverage.
  4. Medicaid. This program covers patients who are welfare recipients. While it is a federal program, it is administered and funded on the state level — thus poorly funded. It is imperative that coverage is verified each time the patient is seen. Moreover, all surgical procedures must be preauthorized.

Variations in Payer Rules and Regulations

Fee schedules. Medicare Part B releases its fee schedule in the fall of each year, effective Jan. 1 of the following year. Historically, there has been a last-minute fee fix to avert drastic cuts, so it is always best to follow the advice from the Academy’s Washington, D.C., office on when to implement a final fee schedule. Commercial payers generally have a fiscal versus calendar year. Fee schedules are updated anytime between April and July. There is no continuity regarding allowables. Some commercial payers base payment structure on relative value units. Others have a different formula.

Modifiers. Medicare Part B recognizes all CPT and Healthcare Common Procedure Coding System modifiers, including the lid modifiers E1 to E4. Commercial plans often don’t recognize modifiers –25 Significant, separate E&M service same day as minor procedure, –26 Professional component, –54 Surgical care only, –55 Postoperative management only, –57 Decision to perform major surgery or –TC Technical component.

Global surgical periods. For Medicare Part B, a minor surgical procedure has zero or 10 days of postoperative care. A major procedure has 90 days of postoperative care. For commercial plans, a minor procedure has either zero, 10 or 15 days, and a major procedure has 45, 60 or 90 days of postoperative care. When preauthorizing surgery with a commercial payer, the best practices always ask for the global surgical period, too, if the information isn’t posted on the payer website.

Correct Coding Initiative (CCI) edits. CCI edits identify code pairs that may or may not be payable separately when performed during the same surgical session. Commercial payers that don’t follow CCI may publish their bundling edits, if they are published at all. These types of edits are referred to as black-box edits.

Next month: Developing Your Fee Schedule

Quiz Answers

  1. When a claim is denied, simply resubmit until payment is made. False. Only if you want to draw negative attention to yourself. Read the denial codes. Determine what errors were made and correct them before resubmitting.
  2. Conducting internal chart audits is mandatory as part of your compliance plan. False. However, while audits are not mandatory, they demonstrate an effort to be compliant. Plus, internal audits allow you to take corrective action, if necessary, rather than having a payer take action.
  3. All payers must follow rules and regulations according to CMS policies. False. There is very little continuity among payers with regards to coverage policies.

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About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series.

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