With a game show format, prizes, and a soundtrack of golden oldies, Code-a-Palooza lives up to its name! At each year’s annual meeting, two teams of volunteers compete against each other and against the crowd, which is equipped with audience-response units.
How would you do at Code-a-Palooza? Try tackling some of the most challenging questions from last year’s event.
Turn Up the Music and See How You Do!
Q1: “I Heard It Through the Grapevine.” The No. 1 question currently submitted to aao.org/coding is: “Does Medicare reimburse us for both services if we perform GDx imaging (CPT code 92133) and an extended visual field exam (92083) on the same patient on the same day?”
Q2: “Happy Together?” “We submitted the Eye visit code for an intermediate established patient (92012), along with codes for fundus photography (92250), serial tonometry (92100), and corneal pachymetry (76514). The commercial BlueShield plan paid all but serial tonometry. Why was serial tonometry denied?”
- It is bundled with the other tests.
- Its CPT description states “separate procedure.”
- It is payable with an E&M code, not an Eye visit code.
Q3: “Do Wah DiddY DiddY” (DiddY). You are researching a surgical code in the Medicare database, and you notice that its global period is listed as “YYY.” Why the “YYY”?
- Why, why, why does it matter?
- Because the surgical code is an add-on code, as in strabismus surgery (e.g., +67320).
- Because it is a code for an unlisted procedure, such as 66999 Unlisted procedure, anterior segment of the eye.
- Because it is a Category III CPT code, such as 0191T, which is used for iStent and Hydrus inserts.
Q4: “Yesterday.” One day before a patient is due to have surgery (which could be major or minor), she presents for a problem unrelated to that surgery. Which of the following statements is true?
- No issues; the exam is payable.
- The exam will be denied because it is a preoperative service that is included in the global surgical payment.
- The exam requires a modifier.
Q5: “For What It’s Worth.” A physician spent 25 minutes talking to the patient and his daughter. No elements of the exam were performed. Which code should you submit to insurance?
- Submit nothing.
Q6: “Every Breath You Take” (They’ll Be Watching You). You perform an exam (99205) and find that the patient has a retinal tear in the left eye and a detachment in the right. Later that morning, you perform extended ophthalmoscopy (92225) and laser (67105) in the office; in the afternoon, you take the patient to the operating room to repair the retinal detachment with vitrectomy (67108). The payer is Medicare Part B.
Q6a: What modifier(s) should be appended to the exam code?
Q6b: What modifier(s) should be appended to the surgical codes?
- 67105–LT, 67108–RT.
- 67105–LT, 67108–79–RT.
- 67105–LT, 67108–59–79–RT.
Q7: “Help!” “A hospital inpatient is seen in our office. An exam and test were performed. I billed from the inpatient family of E&M codes with hospital as the place of service. I got paid for the exam but not the test. Why?”
- The test may have been bundled with the exam.
- The practice should have submitted only the technical component since the equipment is owned by the practice.
- The practice should have submitted only the professional component.
1: A—yes. CCI does not currently bundle 92133 and 92083, which are therefore both payable. Tip: Each test can have frequency edits that may vary by payer, so be sure to check your payer’s policy. Furthermore, some payers may not consider it medically necessary to perform both tests—optic nerve evaluation and visual fields—together or separated by a short period of time. However, they may consider it appropriate to alternate use of these tests at the proper time intervals.
2: B—CPT description. Some non-Medicare payers may not allow payment the same day as an exam because of the “separate procedure” wording in the code’s description.
3: C—unlisted procedure. Unlisted procedure codes may have “YYY” listed as the global period. This means that the carrier, rather than CMS, determines whether the global concept applies and establishes a postoperative period, if appropriate, at the time of pricing.
4: B—denied. Unfortunately, there is no modifier available to indicate that the exam is unrelated to the procedure. Even listing the unrelated diagnosis wouldn’t be enough; to get paid, you would need to go to review.
5: D—submit nothing. You can’t submit an exam code when no medically necessary elements of the exam have been performed.
6a: C—99205–25–57. Because the exam was performed the same day as a minor surgery (67105), append modifier –25 to indicate that the exam was a significant and separately identifiable service. Modifier –57 indicates that the decision to perform major surgery (67108) was made at this exam. (Note: You cannot use –25 if the exam was performed solely to confirm the need for the minor surgery.)
6b: B—67105–LT + 67108–79–RT. CCI bundles 67105 with 67108, which may tempt you to use modifier –59 to unbundle them. But the two procedures were performed on different eyes; therefore there is no need to unbundle them.
7: C—only the professional component. Because the patient is currently an inpatient, it is as if the hospital owned the equipment. Remember to use place of service code 21 to indicate inpatient hospital.
Ms. Vicchrilli is Academy director of Coding and Reimbursement; Mr. Baugh is program manager of Revenue Cycle Integrity and Quality Improvement Programs at the John A. Moran Eye Center in Salt Lake City.