By Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
During the past year, what lessons have your colleagues learned about avoiding costly coding errors? The 14 tips below came from physicians, administrators, and techs, as well as from coders and billers.
1. When called to the emergency department (ED), you can use ED codes even though you are not an ED physician.
2. When examining a hospital inpatient, you should report the place of service as hospital—even if you see the patient in your office.
3. When two physicians of the same specialty see the same patient on the same day for the same diagnosis, only one should submit a bill for the exam. Ophthalmology is one specialty.
4. When you examine only one of the patient’s eyes, never append modifier –RT or –LT to the exam code.
5. Tests performed within the global period of a surgery, whether related or unrelated to that surgery, are billable provided they are medically necessary.
6. Because tests do not have a global period, you should never append modifier –25 to the exam when another test (not a minor surgery) is performed on the same day.
7. Sometimes you need to repeat the same test on a patient. If you’re not sure how many times Part B Medicare pays for the test, and you’re ordering that test more times than you normally do, you should obtain an Advance Beneficiary Notice (ABN) from the patient. Similarly, obtain an ABN when you don’t know whether the patient’s insurance will accept a particular diagnosis code as justifying performance of a particular test.
8. A retina OCT (CPT code 92134) and a glaucoma OCT (CPT code 92133) are never both payable on the same day. The two codes have a mutually exclusive edit in the National Correct Coding Initiative (CCI), and CPT code instructions tell you that they can’t both be paid on the same date of service.
9. It pays for you to verify each combination of CCI. For instance, although selective laser trabeculoplasty (SLT, CPT code 65855) is not bundled with gonioscopy (CPT code 92020), gonioscopy is bundled with SLT.
10. There is no need to append modifier –25 to a new patient exam when a minor surgery is performed the same day as a separately identifiable exam.
11. You can use modifier –58 to be paid for additional surgery within the global period of an earlier surgery— for instance, when the second procedure is more difficult than the first.
12. Unplanned postop procedures that are performed in the office’s dedicated procedure room are payable. The old rule that postop surgeries were only payable in the facility setting has not been in force for many years.
Bilateral Surgical Procedures
13. Different payers have different requirements for submitting bilateral surgical procedures. Some payers, like Medicare Part B, require a single line item appended with modifier –50 and a “1” in the unit field. Some require a single line item appended with modifier –50 and a “2” in the unit field. And others require two line items with modifiers –RT and –LT. Regardless of how you report it, correct payment is 150 percent of the allowable. There is no way to avoid the 50 percent reduction in payment for the second eye.
Local Coverage Determinations
14. Stay up to date with local coverage determinations (LCDs). One AAOE member noted that he would have been better prepared for a Recovery Audit if he had been familiar with the LCD guidelines required at the time of the surgery. Medicare contractors update the policies more frequently than he had realized.