Part 3 of this series identifies reasons to review these topics before you bill for your testing services.
- Routine and standing orders
- Correct Coding Initiative Edits
- Testing services while patient is in a skilled nursing facility or hospital
- Multiple procedure payment reduction
- Interpretation and report
- Identifying the referring, ordering or supervising physician
Routine and standing orders
While striving to streamline the patient encounter, don’t forget important payer rules. Only hospitals can have standing orders for tests –never physician practices. Insurance protocol mandates that new patients are evaluated by the physician and then medically necessary tests can be performed and/or delegated. Failure to follow this rule will, upon audit, result in a recoupment of payment.
For established patients, the order delegating test(s) may be in the previous chart note. Be sure that part of the chart is included in the documentation submitted to the payer.
Correct Coding Initiative Edits
Tests can be bundled with other tests. Tests can be bundled with surgical codes. Bundled codes may vary by payer. Medicare and payers who follow Medicare are guided by the National Correct Coding Initiative (NCCI), Correct Coding Initiative (CCI) edits. These edits are published quarterly; Jan 1, April 1, July 1 and Oct 1 of each year. CCI edits can be found at aao.org/coding with a link to the CMS excel files, and in the Coding Coach complete Ophthalmic Coding Reference and Retina Coding Complete Reference Guide. Commercial plans that do not follow CMS, have their own software edits such as those complied by McKesson. Often these edits are not published and referred to as black box edits. Remember to check each combination of codes.
CPT code 92020 Gonioscopy is bundled with 65855 Argon laser trabeculoplasty when performed the same day as the laser procedure.
Visual fields, CPT codes 92081, 92082 and 92083 have a mutually exclusive edit with 15823 Blepharoplasty surgery when performed the same day indicating it is never appropriate to unbundle the field from the surgery.
92201 Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (eg, for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral, is bundled with nearly all retina surgical procedures.
And lastly, the bundle familiar to all in ophthalmology is the bundling of CPT 92133 glaucoma and/or 92134 retina OCT with 92250 Fundus photography.
Testing Services while Patient is in a Skilled Nursing Facility or In-patient Hospital
When a patient is receiving care in locations such as a skilled nursing facility (SNF) or inpatient hospital, it is as if the facility owns the testing equipment --even when the test is performed in your office. Therefore, appropriate billing is to submit only the professional component (modifier -26) of any test.
If you are unaware the patient is in one of these locations and you submit the test as usual, payment may be made, but upon patient release from the facility, a recoupment letter will be sent to you immediately. And the recoupment will be for the entire payment, not solely for the technical component.
Multiple Procedure Payment Reduction
On January 1, 2013, CMS announced a multiple procedure payment reduction (MPPR) impacting all ophthalmic testing codes that can be delegated.
When multiple tests are performed on the same patient, the same date of service, the technical component (-TC) for the second and subsequent test is automatically reduced by 20 percent. Often CMS appends modifier -51 to the test indicating which test(s) received the reduction. To clarify, practices should not append modifier -51, but CMS often does.
An exam, a 92083 Visual field and 92133 RNFL are performed.
Payment will be:
- 100 percent of the allowable for the exam
- 100 percent of the allowable for the visual field
- 20 percent reduction of the technical component of the RNFL
Remember, it is not necessary to submit tests using the -TC and -26 modifiers. The reduction is automatically calculated.
CMS monitors physician billing patterns so it is wise not to perform tests on different days solely to avoid the 20 percent reduction of the second and subsequent test.
Interpretation and Report
Here are the facts:
What the report says is up to the physician.
The report may include notation of any findings that confirm a diagnosis; reveal a need for change in treatment; indicate if the condition is improved or worsening.
The interpretation and report required for all tests does not have to be a separate dictated report. It can be written on the test, or in the medical record, or on a testing flow sheet. It must be available to an auditor upon request
Technicians and photographers must develop a fail-safe way to ensure that the physician documents within a timely manner. The physician must initial or sign the interpretation.