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  • Savvy Coder

    Top Real-World Coding Competencies for Young Ophthalmologists—Part 2

    By Janice Law, MD, Academy YO Committee Chair and Vice Chair for Education at Vanderbilt University Medical Center, and Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement
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    New to coding? This two-part series provides tips to help you to stay out of the auditors’ crosshairs while you learn the ropes. (See Part 1 in last month’s EyeNet for some tips on cheat sheets.)

    Modifiers and the Global Period

    The first rule of modifiers is to under­stand global periods and know whether your patient is in one.

    What is the global period? For sur­gery, the payer’s coverage is known as the global surgical package, which in­cludes pre- and postoperative services. For Medicare, the post-op period for major procedures is 90 days; for minor procedures, it is zero or 10 days. Don’t make assumptions about which proce­dures are major and which are minor. For example, a YAG capsulotomy (CPT code 66821) is a major procedure, but a YAG peripheral iridectomy (CPT code 66761) is minor.

    Why does it matter? When a patient encounter takes place during the global period of a procedure that was per­formed by you (or somebody else in your practice), the payer is likely to assume that the encounter is covered by the global surgical package. If the encounter isn’t covered by that package, you can flag that fact by appending a modifier to the CPT code. For example, if a “significant, separate” eye exam is performed on the same day as a minor procedure, you can bill for it using modifier –25 (but make sure that your documentation meets the modifier’s requirements). And if an exam to deter-mine the need for a major surgery takes place within 24 hours before surgery (or within three days, for some payers), you would need to append modifier –57 to the exam’s CPT code (see “Ef­fectively Use Exam Modifiers,” at aao.org/young-ophthalmologists/yo-info/article/effectively-use-exam-modifiers). Similarly, if you perform a surgery during a global period, and you deter­mine that it isn’t covered by the earlier procedure’s global surgical package, you will need to append a surgical modifier (such as –58, –78, or –79) to avoid a claim denial (see “Billing for Ophthal­mic Surgery: 10 Steps for Successful Coding,” Savvy Coder, June 2022).

    Action step—find out the practice’s procedures for identifying a patient’s global period. How do you know if your patient is in a global period? Confirm the practice’s workflow for promptly identifying a patient’s global period in the exam lane or when coding surgical procedures. Some practices may use the EHR system to track and flag the postoperative days whenever a procedure is performed. Other practic­es may identify past procedures in the chart or on the superbill. Remember, when a procedure is performed in a group practice, the patient’s global peri­od applies to all the practice’s ophthal­mologists, regardless of subspecialty.

    Tip: Is a visit on post-op day 88 or 91? You can use online tools (e.g., https://timeanddate.com) to determine how many days have elapsed since the day of surgery.

    New or Established Patient?

    Reimbursement for an eye exam is higher for a new patient than an established patient. According to CPT’s definition, patients are consid­ered new if they haven’t been seen by you or by a physician from the same group practice within the last three years. Coding appropriately is essential, as payers and auditors constantly moni­tor the use of new patient codes.

    Action step—recognize the nuanc­es. Keep in mind that a patient is not considered new if referred to you by another physician within your practice, even when your subspecialty is differ­ent from that of the referring physician. To review some case studies, see “Is the Patient New or Established? Test Your Knowledge” (Savvy Coder, August 2019).

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    You also can download exam and surgery quick reference guides from the Academy Coding Fact Sheet and Resources web­page at aao.org/practice-management/coding/updates-resources.

    Don’t Use a Partner’s NPI!

    Often on the first day of practice, a young ophthalmologist may be waiting for credentialing from some insurance payers. If this happens to you, don’t be tempted to bill for services us­ing your senior partner’s National Provider Identifier (NPI). If the payer catches this billing error, one or both of the physicians may be audited and the funds recouped with penalties—and there is even a risk of your practice being monitored with prepayment reviews.

    Action step—track the credentialing process. Immediately after signing your employ­ment agreement, be sure to proactively support the practice team during the credentialing process. If your new job involves moving to a new state, apply for that state’s medical license and monitor and resolve any problems that might delay the process. (Licensing can take up to six months.) Provide all credentialing information to your team and track the process. Are your professional references not responding to credentialing requests? Speed things up with a reminder phone call.

    Once you are in practice, track the payers that have approved credentialing and have staff schedule patients accordingly. Suppose a patient needs to be seen urgently? If you are a nonparticipating physician with the insurance plan, notify the patient and follow the rules of the No Surprises Act that went into effect on Jan. 1, 2022 (see aao.org/practice-management/coding/surprise-billing).