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Why Physicians Must be Competent Coders, Part 1
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As a physician, your staff can and should be of tremendous assistance when it comes to the complexity of coding. However, far too often, staff have not received a firm coding foundation or had access to ongoing education from an appropriate source. As a result, coding errors and audits occur and physicians pay back thousands of dollars due to simple errors. Because physicians are ultimately responsible for CPT and diagnosis code selection, as well as chart documentation, you, yourself must be a competent coder.

The following are three costly coding errors impacting ophthalmology.

Error #1
The ophthalmologist submits a claim for an exam and extended or subsequent ophthalmoscopy the same day as a retinal surgical procedure. The exam and surgery is paid, but the extended ophthalmoscopy is denied. Why?

Effective July 2013, the National Correct Coding Initiative bundled all retinal surgical codes with “extended” (CPT code 92225) or “subsequent” (CPT code 92226). Only when the ophthalmoscopy is performed for a diagnosis unrelated to the surgery performed on the same day is it appropriate to unbundle so that both procedures can be paid. In those cases, append modifier –59 separate procedure to CPT code 92225 or 92226. The payment summary notice received by the patient states that the testing service is included in the surgery and is not separately billable by insurance or the patient.

Remember, it is appropriate to submit 92225 extended ophthalmoscopy when a drawing is made to document pathology that can’t be documented in any other way. The drawing must be detailed and labeled. When the patient is seen in follow-up for the same diagnosis and there is change in pathology that is both drawn in detail and labeled, it is appropriate to submit 92226 subsequent ophthalmoscopy.

Error #2
A practice administrator writes, “Often, the surgeon performs bilateral surgery, including bilateral laser surgery. We have over 20 claims where the second eye is denied payment. Has the rule changed? Should we be writing off the second eye charge?”

Effective April 1, 2013, according to medically unlikely edits, all surgical procedures, when performed bilaterally, must be submitted as a single line item appended with modifier –50 indicate bilateral performance and a “1” in the unit field for Medicare Part B patients. Payment remains the same at 150 percent of the allowable.

What about other non-Medicare payers? Commercial payers may require bilateral surgeries to be billed as a single line item with modifier –50 and a “2” in the unit field. Many commercial payers require a two-line item appended with modifiers –RT/–LT.

Error #3
Fact or fiction? Testing services performed during the global period are only billable if there is a change or if unrelated to the surgery.

Both statements are fiction. Testing services, whether related or unrelated, change or no change indicated, are billable and payable during the global period — when medically necessary to be performed.

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About the authors: 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.

Academy members: login to read or make comments on this article.