The Academy has received a handful of reports of isolated problems related to the two-week old ICD-10 transition. Some private plan and carrier errors have emerged, causing some initial payment issues related to glaucoma diagnosis codes and the family of cataract codes.

Ophthalmologists are urged to check their claim statuses periodically. They should then work with their Medicare administrative contractors to resolve any issues. If the problems persist, physicians should email the ICD-10 ombudsman.

Reported issues

• An Aetna Medicare Advantage plan did not recognize glaucoma diagnosis codes for Current Procedural Terminology code 92133 for ophthalmic diagnostic imaging. An investigation revealed that Aetna has based its denial on a national coverage policy for 92134 (retina ocular coherence tomography).
• The family of cataract codes 366.16 in ICD-9 to H25.-11 to H25.13 ICD-10 age-related nuclear cataract was denied as routine with Humana Medicare Advantage, WPS and CGS.

The Centers for Medicare and Medicaid Services previously announced that payment would be made when a submission is from the correct code family. This is apparently not always the case.

Success stories

• Novitas local coverage determination for ophthalmic diagnostic imaging did not include diabetic retinopathy with macular edema diagnoses. With assistance from Academy coding staff and carrier ophthalmology advisor John Haley, MD, the omissions have been identified. A correct policy is already in place.
• First Coast corrected its visual field policy to include glaucoma suspect as a covered diagnosis codes.

Take steps to resolve any issues

Physicians should take the following actions when ICD-10 denials are received:

1. Make sure the error is with the payer, not you.
2. Notify the payer by phone review. Demonstrate that it was covered in ICD-9 and should be covered in ICD-10. If there is no resolution, the physician should email the CMS ICD-10 ombudsman William Rogers, MD, at ICD10_Ombudsman@cms.hhs.gov. Once he has been notified, his team will research the issue.

CMS has also issued a new ICD-10 Resource Guide and Contact List to help physicians find answers to their questions, with state-by-state contacts listed.