|Final Determination of E&M Code 12/03/2014|
Over the past few months, YO Info has taken a look at the documentation requirements for the history, exam and medical decision-making. Now it’s time to select the appropriate level of service. While billers, coders and allied health personnel may assist with this, physicians are ultimately responsible for code selection.
|E&M Documentation Requirements, Part 5: Making Sense of Medical Decision-Making 10/07/2014|
E&M documentation includes the history, exam and medical decision-making. Over the past few months, YO Info has taken a look at the three elements of the history as well as the exam. This month, we turn our focus to medical decision-making. Sometimes abbreviated to MDM, this part of documentation reflects the patient’s final diagnosis and progress as well as the response to and changes in the treatment plan.
|Increase Your Coding and Reimbursement Expertise at AAO 2014 09/18/2014|
Have you tested your coding knowledge lately? If not, this 20-question self-assessment can give you a quick benchmark. If you plan to attend AAO 2014 in Chicago, your quiz results can help you plan what coding courses to take.
|E&M Documentation Requirements, Part 4: The Exam 08/12/2014|
Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. This month, we turn our focus to the eye examination, which is comprised of 12 elements. These elements are performed as medically indicated by the patient’s chief complaint as well as any specific complaints.
|E&M Documentation Requirements, Part 3: The Chief Complaint and Elements to the History of the Present Illness 07/15/2014|
Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. This month, we’ll look at the chief complaint and elements of the history of the present illness. These two components provide the reason for the encounter and indicate what elements of the exam are medically necessary to perform.
|E&M Documentation Requirements, Part 2: A Look at Past, Family and Social History 06/17/2014|
Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. It’s also necessary for both risk management and coding compliance. This month, we’ll take a look at past, family and social history (PFSH).
|E&M Documentation Requirements: A Look at ‘Review of Systems’ 05/13/2014|
Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. It’s also necessary for both risk management and coding compliance. Ophthalmology practices can use both E&M and Eye codes, but each has its own documentation requirements. This month, YO Info will focus on one piece of the E&M puzzle — the review of systems.
|What You Didn’t Learn in Medical School About Proper Documentation 04/17/2014|
Proper documentation isn’t necessarily addressed in medical school. Yet, it’s a critical factor in both getting your claim paid and having to pay back hundreds of thousands of dollars in an audit. In this addition of YO Info, we’ll focus on some of the documentation basics for the various services a physician provides.
|Why Physicians Must Be Competent Coders, Part 2 03/18/2014|
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 members 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, each physician must be a competent coder.
|ICD-10 Prep Ramps Up with Testing Week, New CMS 1500 Form 02/10/2014|
ICD-10 is coming — there is no delay. Your time to prepare for the biggest change to coding in 30 years is now. All practices must be ready to transmit ICD-10 codes on Oct. 1; beginning that date, all ICD-9 codes will be rejected. To help practices prepare for the change, CMS and Medicare administrative contractors will host an ICD-10 test week from March 3 to 7.
|Why Physicians Must Code Competently, Part 1 01/14/2014|
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 has 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.
|12 Questions to Ask When Hiring Billing Staff 12/03/2013|
Ophthalmologists rely on billing staff to help keep the office compliant and maximize reimbursement. When recruiting billing staff, many practices look for applicants with little or no billing experience, thinking that if they are 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.
|Eye or E&M Code? That Is the Question 10/15/2013|
Ophthalmologists have two types of office visit codes to choose from: Eye codes (92XXX) and E&M codes (99XXX). What are their similarities and differences? YO Info breaks them down.
|Telling a Story with Modifiers: A Primer on Coding 09/17/2013|
What do you need to know about modifiers? Everything … period. Applying modifiers is like telling a story to the payer — they indicate that the exam, test and/or surgery billed has been altered or modified in some way. And for claims to be paid correctly, they are vital. Their incorrect usage — as well as their absence altogether — are two major reasons payers reject claims. As a result, modifier misuse can severely impact your practice’s bottom line.
|Recent CCI Edits Significantly Impact Ophthalmology 08/13/2013|
Effective July 1, Correct Coding Initiative (CCI) edits version 19.2 bundled all established patient exam codes (both E&M and Eye codes) with all major and minor surgeries. Unfortunately, CMS has not given Medicare administrative contractors clear direction on how to implement these new edits or contractors have not adopted the corrections. As a result, exams are being denied. Also, several sources have provided erroneous information about the edits.
|Coding Q&A — Your Questions Answered, Part 3 07/15/2013|
The American Academy of Ophthalmic Executives has lately received a host of interesting questions inquiring about different coding-related matters. Below is a third installment of the standouts. courses, online tools and products related to coding.
|Coding Q&A — Your Questions Answered, Part 2 06/10/2013|
The American Academy of Ophthalmic Executives has lately received a host of interesting questions inquiring about different coding-related matters. Below is a second installment of the standouts. courses, online tools and products related to coding
|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:
|The Technician’s Role in Obtaining the Advance Beneficiary Notice 07/13/2009|
Who has the responsibility to inform patients about the possibility that the test or surgical procedure they are to undergo may or may not be covered by Medicare? Quite often, it is the ophthalmic assistant or technician. The new and improved Advance Beneficiary Notice (ABN) — renamed the Advance Beneficiary Notice of Noncoverage — became effective March 1. This Medicare form replaces the former ABN-G and the Notice of Exclusion of Medicare Benefits.
|Testing Before Cataract Surgery: When to Use OCT 05/11/2009|
The American Academy of Ophthalmic Executives (AAOE) receives many coding questions concerning cataract surgery. One in particular caught our eye. It involved the use of an optical coherence tomography (OCT) on diabetic and age-related macular degeneration (AMD) patients prior to cataract surgery, to investigate and discriminate the cause of vision loss.
|Who Fits the Bill? 12 Questions to Ask When Filling a Billing Vacancy 04/13/2009|
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.
|Getting Medicare-Secondary-Payer Claims Right the First Time 02/10/2009|
When is Medicare not responsible for primary payment for beneficiaries’ medical claim? CMS has detailed this issue in a fact sheet for physicians and administrators. Medicare secondary payer (MSP) is the term used by Medicare when Medicare is not responsible for paying a claim as primary.
|Be Prepared for an Audit 01/12/2009|
When ophthalmologists are audited and they want the best-case/worst-case scenario, they tend to call me. It is interesting to note that when a physician calls, he/she begins with, "Guess what my staff has done wrong." And when a staff person calls, the conversation tends to begin with, "Guess what the doctor has been doing incorrectly." While it is true that the physician is ultimately responsible for documentation and subsequent code and diagnosis code selection, staff must be of immediate and ongoing assistance. Here are three ways your office can be prepared for an audit.
|Costly Coding Errors 10/15/2008|
The six examples presented are real. Each case presents the:
* Financial Impact
|Common Coding Errors 08/18/2008|
To help you navigate the often-confusing world of coding, we’ve compiled several of the most common coding errors and the correct way to code these procedures. Topics include: suture removal, benign and malignant skin lesion removal, complications during the global period, exam before second eye surgery, two providers same day and A-scan coding 76519 and 92136.
|Fraud or Abuse? You Make the Call on Coding Mistakes 06/18/2008|
As reported to the Academy, Medicare is currently auditing the following coding mistakes. Some are the result of focused medical review audits, others from whistle blowing cases. Auditors will determine if these errors are a result of coding mistakes or an intentional act.
|2008 CPT Update 01/25/2008|
A quick overview of the six significant changes in CPT impacting ophthalmology for 2008.
|Coding Q&A 01/25/2008|
Following the morning session of the YO Program at the Annual Meeting in New Orleans, several people had some very specific coding questions. Here are the more common questions and their answers, as provided by Sue Vicchrilli, the coding executive for the American Academy of Ophthalmic Executives.