When residents get ready for real-world practice, they’ll ask themselves, “What should I know about reimbursement before my first day on the job?” Key first steps toward coding proficiency should include mastering the concepts described below and in next month’s Part 2.
Who Is the Payer?
The first rule of coding is, “Who is the payer?” Each insurance payer has unique policies that often provide the documentation requirements, frequency limitations, and covered diagnosis codes for ophthalmic services.
Different payers can have different rules. CMS publishes national coverage determinations (NCDs), and Medicare Administrative Carriers (MACs) provide local coverage determinations (LCDs) and articles (LCAs). Although Medicare establishes its guidelines, the commercial, Medicaid, and Medicare Advantage payers can make their own rules.
Example of how rules vary. How should you document a functional blepharoplasty (CPT code 15823)? The answer depends on your payer. Noridian, which is the MAC for 13 states and three U.S. territories, requires eyelid photos, patient complaints, and physical signs as outlined in LCD L36286. WPS, which is the MAC for six states, requires visual fields (VFs) but not photos, per LCD L34528. Moreover, commercial plans often require prior authorization for blepharoplasty and may require both VF testing and photos for the approval process, as described in Aetna’s policy bulletin #0084.
Action step—know your payers’ rules. Familiarize yourself with your local MAC’s policies, which you can find at aao.org/lcds. During the first three months of practice, ask your employer or practice manager for the list of the top five insurance payers and any internal resources that outline the nuances of their reimbursement rules. Learn how the policies of your non-Medicare payers differ from those of your MAC.
Master Your Top CPT Codes
Each CPT code has a written description and is assigned Relative Value Unit (RVU) values, which are used to calculate reimbursement. Other details that you’ll want to know about a CPT code include whether it is bundled with any other CPT codes (and if so, whether it can be unbundled); whether it is unilateral or bilateral; which diagnosis codes are covered; which modifier codes can be appended; and, for surgeries, the length of the global period.
Action step—create a cheat sheet. What are your top procedures? While still in training, you should copy down the CPT codes of services that you expect to frequently perform in the office and OR. Include codes for office visits, testing services, and surgeries in your subspecialty. Don’t overlook those brief office services that you might take for granted, like gonioscopy, pachymetry, or epilation. Research the CPT codes for these services using the Academy’s Coding Coach (aao.org/codingtools) and the CMS Medicare Physician Fee Schedule Look-Up Tool (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup).
Based on your research, create quick cheat sheets. The key is to have reference cards that young ophthalmologists (YOs) deem functional. For many, a typical reaction is: “I may not understand it completely, but at least I have these tools to get me started.”
Web Extra: Create cheat sheets that are small enough to hang with your work badge or fit in your coat pocket. Download some templates (Word.doc) to help you get started.