|Coding Q&A — Your Questions Answered 05/14/2013|
The American Academy of Ophthalmic Executives has lately received a host of interesting questions inquiring about different coding-related matters. Below is a selection of the standouts.
|Still Time to Avoid the Penalty — Get Cracking on PQRS and E-Prescribing 04/15/2013|
In 2007, CMS established the Physician Quality Reporting System (PQRS), a pay-for-reporting program that includes claims- and registry-based reporting of data on individual quality measures or on a cataract group measure. PQRS was the first of three incentive programs that also include e-prescribing and meaningful use. While the early phases of these programs included only positive payment adjustments for participation (i.e. bonuses), CMS will soon begin phasing in negative adjustments — penalties — for those who don’t participate or don’t report successfully. Though these cuts won’t take effect until 2015, they’re based on what you do this year.
|The ABN Explained 03/11/2013|
When there is a doubt whether Medicare Part B will cover a service, it is always best to obtain an ABN from the patient before performing the services. Instances in which there would be doubt include uncovered diagnosis code, an oculoplastics procedure that may be determined to be cosmetic rather than medically functional or when frequency is exceeded. Certain services are considered statutorily excluded and do not need an ABN signed in advance from the patient. These include refraction services, routine vision care, cosmetic surgeries (including LASIK) and off-label/noncovered services.
|Coding and Reimbursement Essentials for Ophthalmologists, Part 2 02/12/2013|
Would you know how -- and if -- to bill for these situations? In this article we'll cover services provided to family members, meetings with the patient's family and whether you can have multiple fee schedules or show payment amounts on claim submissions.
|What Every Ophthalmologist Must Know About Coding and Reimbursement, Part 1 01/14/2013|
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.
|Surgical Modifiers: Part 2 12/04/2012|
When it comes to surgical procedures, modifiers convey to the payer a detailed story of exactly what occurred during the operative session. And since surgical claims cannot be paid correctly if submitted incorrectly, it’s imperative to get the modifier story straight the first time. As such, this series of articles will detail exactly which modifier should be used in a variety of surgical cases.
|Need a Coding Crash Course? What to Take at the Joint Meeting 10/16/2012|
Does your coding competence equal your coding confidence? If not, the Joint Meeting is a great place to increase your expertise. Several intensive sessions at this year’s Joint Meeting are designed to enhance participants’ knowledge of appropriate coding and documentation and ensure proper reimbursement.
|Surgical Modifiers: Part 1 09/10/2012|
When it comes to surgical procedures, modifiers convey to the payer a detailed story of exactly what occurred during the operative session. And since surgical claims cannot be paid correctly if submitted incorrectly, it’s imperative to get the modifier story straight the first time. As such, this series of articles will detail exactly which modifier should be used in each surgical condition.
|Surgical Coding 101, Part 2: What’s Not Included in the Global Surgical Package? 08/14/2012|
Building on last month’s introduction to surgical coding fundamentals, which covered what’s included in the global surgical package, we now turn to coding what's not included. If medically necessary and appropriately documented, the following services — which are not included in the global surgical package — may be billed separately.
|Surgical Coding 101 07/16/2012|
Insurance companies classify surgical procedures as either minor or major. Minor procedures have zero or 10 days of postoperative care for Medicare and zero, 10 or 15 days of postoperative care for non-Medicare payers.
Major procedures have 90 days of postoperative care for Medicare and 45, 90 or 120 days of postoperative care for non-Medicare payers.
|Regulatory Updates for 2012 06/11/2012|
With all of the rapidly occurring coding changes, there are a few that deserve particular attention. These include audits, the ICD-10 transition and updates to the Physician Quality Reporting System and e-prescribing incentive programs.
|Coding Is a Team Sport 05/14/2012|
While the physician is ultimately responsible, it takes the entire ophthalmic team to stay current with coding changes, implement the updates into the practice, submit the claim and then process (or resubmit) the explanation of benefits correctly. I often joke that if we saw only one or two patients a day, we’d get it right 100 percent of the time. Obviously, we see substantially more patients with a plethora of insurance coverage — all of which may vary. How do you keep up? One solution is to dedicate a part of each staff meeting to coding updates or a coding quiz to make sure the team is on the same playing field.
|Nine Key Coding Lessons: Your Colleagues’ Favorite CODEquest Insights 04/16/2012|
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.
|Acquiring a Detailed Patient History for Common Eye Emergency Cases 03/12/2012|
“I need to see the doctor right away — and I don't have an appointment.” Staff is often on the receiving end of this request, either by phone or in person, and they need to decide quickly which patients should see a physician and when. Front-desk staff may not be trained for this sort of evaluation, but physicians should be able to help triage ocular emergencies and schedule patients accordingly. Your practice can simplify the choices by dividing clinical presentation into four tiers.
|To Charge or Not to Charge Interest: Medicare Billing Fees Explained 02/13/2012|
One question on everyone’s mind lately seems to revolve around the appropriateness of charging Medicare patients interest on past-due amounts. Here's the bottom line from CMS regarding charging interest, etc., to Medicare beneficiaries.
|Update on Recovery Audit Contractors 01/18/2012|
In addition to focused medical review, comprehensive error-rate testing (CERT), and Office of Inspector General and Medicare Advantage plan audits, ophthalmology can add recovery audit contractors (RAC) to the list of growing types of mandated audits.
|What’s in a Name? Defining and Understanding Local Coverage Determinations 12/05/2011|
Though it’s a far cry from the infamous feud between the Montagues and Capulets, there can be an occasional conflict on exact coverage policy between physicians and Medicare Part B payers. To help you avoid becoming part of such conflicts, here’s a quick guide to local coverage determinations (LCDs).
|Solving Eight of Your Coding Concerns 10/11/2011|
When it comes to CPT codes, it can be confusing at best and downright costly at worst. Here are eight common situations and the (usually) quick solution.
|Interpreting the Remittance Advice 08/15/2011|
“Look at the amount we billed. Look at what the insurance company allowed. Write off the difference and bill the patient or the second insurance the difference.” Those words were the only training I received when I started processing the explanations of medical benefits now referred to as remittance advice (RA). The reality is there is so much more to know.
|Accuracy or Abuse? Appropriately Applying the ABN 06/13/2011|
More paperwork. Just what the patient and the office needs. Yet the Advance Beneficiary Notice (ABN) is a crucial safety net for payment when used correctly. This article is designed to set the record straight on instances where it is appropriate to use the ABN and when it is not.
|Inside Information on Successful Coding 05/16/2011|
These coding tips will help you achieve documentation compliance, which will result in proper payment of claims the first time.
|Avoiding an Audit: History-Taking and the Components of the Chief Complaint 04/18/2011|
Simply hearing the word “audit” can cause anxiety in any physician…and with good reason! Yet, there are simple steps you can take to protect yourself. For example, did you know that the number one reason physicians don’t do well in a third-party payer audit is due to an inadequate history to support the level of documentation billed — particularly in a new patient exam? Let’s review the chief complaint and the three components of history-taking in E&M (evaluation and management) coding.
|Ophthalmic Abbreviations 101 03/14/2011|
Have you noticed how the ophthalmic community seems to talk in code? PT w/? IOP f/u VF OU. And sometimes we even make-up our own abbreviations system. To avoid confusion or even embarrassing mistakes, here are some of the most commonly used appropriate abbreviations. Use them for standardize documentation in the medical record.
|Coding Tips for the Young Ophthalmologist 02/14/2011|
One way of attracting unwanted audit attention is duplicate claim submissions. A duplicate claim is defined as a claim submitted to Medicare from the same provider, for the same beneficiary, for the same item or service, for the same date of service.
|Misuse of Modifier -79 12/06/2010|
The Office of the Inspector General (OIG) recently issued a Management Implication Report on the misuses of the modifier -79.
|Ophthalmology Coding, Pt. 2: Keratoplasty to YAG Capsulotomy 06/14/2010|
Last month, we began highlighting key points in coding the services most frequently performed in ophthalmology, from A-scan ultrasound for intraocular lens calculations through foreign body. This month, we’ll pick up with keratoplasty.
|Ophthalmology Coding, Pt. 1: A-Scans to Foreign Body 05/26/2010|
Remember the pirate’s often-lost wooden eye in Pirates of the Caribbean? Or Tom Cruise’s eye transplant in Minority Report? Movies showing eye injuries intrigue us. Although it is a challenge to code these incidents, an even greater challenge lies in correctly coding the ophthalmic procedures we see daily. Our focus is to begin highlighting key points in coding the services most frequently performed in ophthalmology.
|CMS Signature Requirements for Medical Review 04/12/2010|
Auditors of recent chart reviews have reported an increase in the number of records reviewed that have unacceptable signatures. Medicare contractors require a legible identifier for services provided or ordered. The signature may be handwritten or an electronic signature may be used. Stamped signatures are not acceptable to sign an order or any other part of the medical record. CMS has clarified what entail acceptable methods of signing records and/or tests.
|Three Tips for Fraud Avoidance When Altering Medical Records 03/15/2010|
Chart audits have revealed that some providers are altering medical records inappropriately. CMS reminds physicians not to alter the documentation after a request for records has been received. Improper altering often fails into two categories.
|Claim Submission: Getting It Right the First Time 02/08/2010|
For those of you who process explanation of benefits (EOBs), what is more frustrating and time-consuming than to have a claim denied, which then requires reprocessing? The truth is, there are mistakes common to all practices that, if avoided, can lead to membership in the “clean claim club.”
|Medicare Update: Reporting Simplified for 2010 E-Prescribing Incentive 01/11/2010|
For successful reporting under the 2010 e-prescribing incentive program, a single quality-data code (e-prescribing G-code) should be reported, according to the following coding and reporting principle: