Coding Lessons Learned in 2021

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For most of 2021, Codequest courses took place virtually. Although attendees weren’t able to network in person, they still got to seek advice on their coding problems, including the examples below.

Cornea—an Extra Step for Transplant Complications

Problem. “We use T86.84 as the base ICD-10 code for corneal transplant complications, with a sixth character appended to add more detail—0: trans­plant rejection; 1: transplant failure; 2: transplant infection; 8: other complica­tions; or 9: unspecified complication. Recently, payers started denying our claims.”

Solution. Each year, CMS publishes a list of ICD-10 codes that is organized alphanumerically. The 2021 version of this list updated T86.84, adding a seventh character for laterality: 1: right eye; 2: left eye; 3: bilateral; or 9: unspec­ified eye. Federal payers would have implemented these changes on Oct. 1, 2020, but other payers may have been slower to do so. To stay current on the diagnosis codes, see “Use These ICD-10 Resources.”

Retina—Documenting the Need for PDT

Problem. “Our practice was unaware that photodynamic therapy (PDT) has a National Coverage Determination (NCD) instead of a Local Coverage Determination (LCD). The NCD details documentation requirements, which our practice had not implemented.”

Solution. The Academy has created a checklist to help you tick off all the NCD’s boxes, including a requirement that is often missing in documentation—evidence of classic choroidal neovascular membrane on fluorescein angiogram. (See “Fact Sheet for Doc­umenting the Need for Photodynamic Therapy,” Savvy Coder, May 2021 at aao.org/practice-management/coding/savvy-coder.)

E/M Versus Eye Visit Codes—a Lot Changed Last January

Problem. “Our practice almost exclu­sively uses Eye visit codes. We were not fully aware of CMS changes in allowables for E/M versus Eye visit codes or the ease of using the new E/M criteria, and we needlessly continued our ticking of boxes for the history and exam.”

Solution. The documenta­tion requirements that we didn’t like about E/M for the past 20+ years disap­peared on Jan. 1, 2021. Office-based levels of E/M are deter­mined by the level of medical deci­sion-making or by physician time on the date of the encounter (aao.org/em). Finally, E/M documentation is the way it should have been all along.

Screening Tests—not Billable Even When Pathology Is Found

Problem. “In error, we were told that when new patients come to the practice, we can perform several tests before they are examined by the physician. That way, when the physician examines the patient, she already has the test data at hand. We didn’t know that these are screening tests and as such are never billable to the payer.”

Solution. Implement an insurance-compliant protocol: All new patients must be examined by the physician and then the physician determines which test(s) are medically relevant to perform or delegate to staff. Standing orders and/or screening tests are never billable to the payer. If you are audited, the payer would recoup payment if you had billed such tests, even when pathol­ogy was found.

Vision Exam or Medical Exam—Check Your Payer’s Policy

Problem. “We don’t participate with vision plans—and historically, we primarily submitted Eye visit codes. Re­cently such claims were denied and the patients were responsible for payment. This makes for unhappy patients.”

Solution. Even outside of vision plans, commercial payers often only allow the use of Eye visit codes for vision exams, with diagnoses such as myopia, hyperopia, and presbyopia. For such payers, bill medical exams with the appropriate level of E/M code.

Cosurgery—When You Can and Can’t Use Modifier –62

Problem. “I just learned that our biller uses the cosurgery modifier (–62) when two surgeons each perform their part of a complicated case and submit different CPT codes.”

Solution. Under Medicare rules, cosurgery occurs when “the individual skills of two surgeons are necessary to perform a specific surgical procedure or distinct parts of a surgical procedure (or procedures) on the same patient during the same operative session.” Ophthalmic instances of this would generally involve two specialists each performing separate components of a surgical case and submitting the same CPT code. The Office of Inspector General is currently examining the use of modifier –62. (To learn more about modifier –62, read “Modifier –62: How to Determine Whether You Can Bill for Cosurgery,” Savvy Coder, May 2020 at aao.org/practice-management/coding/savvy-coder.)

A/R—Are You Below Par?

Problem. “I had no idea our claims denial rate was so high and that our accounts receivable (A/R) figures were so poor compared with other practices, according to benchmarking data from the AAOE’s AcadeMetrics [aao.org/academetrics].”

Solution. Return to the basics and really get to know your numbers. Evaluate your registration process; establish procedures for clean claim submissions; check that payments are posted prompt­ly; review your process for addressing denied claims; and resolve outstanding balances within 24 hours. You also should review and address credit bal­ances monthly.