How well has ophthalmology handled the transition to ICD-10? Looking back, it appears that ophthalmology practices scored an A for preparedness. Payers, however, haven’t done so well thus far.
Problems with ICD-10 codes that had no ICD-9 equivalent. Payers were focused on converting ICD-9 codes into ICD-10 codes and sometimes overlooked those diagnoses in ICD-10 that had no precursors in ICD-9. For instance, there is a family of ICD-10 codes for diabetes with diagnoses that had not been represented in ICD-9 at all—and many payers failed to link those codes to CPT code 92134, which is used for scanning computerized ophthalmic diagnostic imaging (SCODI) of the retina. Consequently, practices were denied payment when they used those ICD-10 codes to justify their use of retinal SCODI. Some practices successfully explained the new code set to payers during a phone review. And in some states, carrier advisory committees (CAC) contacted payers about these omissions. In many states, the payer automatically corrected the claim without asking practices to go through the resubmission process.
Insisting on more specificity than CMS requires. In July, CMS stated that, during the first year of ICD-10, payment would be made if a code was submitted from the right code family, even if it wasn’t the precise code that the regulations appeared to require. The goal of this was to provide practices with a margin of error while they get up to speed. However, CMS initially denied several codes from the cataract family, stating they were “investigational.” Again, phone reviews and contact from CAC representatives reversed these denials.
Denying medical claims. One payer inappropriately denied thousands of medical claims in which practices had reported refractive or routine diagnoses. Once this was brought to the payer’s attention, the payer made a mass correction of those denied claims.
Applying the wrong coverage policies. At least one Medicare Advantage plan failed to recognize glaucoma diagnosis codes for CPT code 92133, which is used for SCODI of the optic nerve. An investigation revealed they had based their denial on a national coverage policy for photodynamic therapy (CPT code 67221)!
5 Tips for ICD-10
The following tips will assist you in finding the correct ICD-10 code and will also help you to make your case when claims are incorrectly denied.
Use ICD-9 to buttress your arguments. For each CPT code, keep electronic or paper copies of the list of diagnoses that were covered under ICD-9. During phone reviews, you can use those earlier coverage policies to support your efforts in securing payment under ICD-10.
Continue using CPT codes to report laterality. Even though many ICD-10 codes indicate laterality, you should still append modifiers –RT and –LT on all CPT codes. When the ICD-10 code also has laterality (or “liderality”), link the right-sided ICD-10 code(s) to the right-sided CPT code and the left-sided ICD-10 code(s) to the left-sided CPT code.
Example: A patient is diagnosed with bilateral cataracts, and the right eye is scheduled for surgery. For the exam CPT code, report the bilateral cataract diagnosis; for the A-scan CPT code (either 76519 or 92136), report the diagnosis code for the right eye.
Refer to Ophthalmic Coding Coach. If your payer hasn’t published a coverage policy for a CPT code, the most efficient source of information is the Ophthalmic Coding Coach (available both as a book and online), which lists the diagnosis codes that payers typically cover for that CPT code.
Review the top 10 questions. Each month, you can read answers to the top 10 ICD-10 and CPT questions that were emailed to email@example.com and firstname.lastname@example.org. Learn from these at www.aao.org/practice-management/coding/ask-the-coding-experts.
Sign up for E-Talk. When members of the American Academy of Ophthalmic Executives (AAOE) are stumped by a problem, they can use the E-Talk listserv. This option for crowdsourcing advice has proved invaluable during the transition to ICD-10.