Ophthalmologists rely on billing staff to help keep the office compliant and maximize reimbursement. When recruiting billing staff, many practices look for applicants with little or no billing experience, thinking that if they are trained in-house, they won’t bring any noncompliant ideas to the practice. However, if you would prefer someone who can hit the ground running, here are 12 questions to test an applicant’s coding savvy:
1. What is the difference between a diagnosis and a procedure? Both a diagnosis (ICD-9) code and procedure (CPT) code are required when filing a claim. The ICD-9 code 365.XX glaucoma, for instance, correlates with the CPT code 92083 visual field. Mislinked diagnosis to CPT codes results in claim denials and can even trigger an audit.
2. What are the differences between the E&M codes and Eye codes for office visits? E&M (99XXX) documentation is nationally recognized by all payers. Eye codes (92XXX) are specific to individual states and payers. Some Medicare Part B carriers have specific local coverage determinations with documentation requirements; others rely on the CPT descriptor.
3. Is CPT code 99213 Established patient level 3 exam paid the same by all payers? No. Payers calculate relative value units differently and incorporate other factors. Therefore, fee schedules for all levels of E&M and Eye codes vary by payer and within subplans of a single payer.
4. How should tests with unilateral payment be coded? “Unilateral” means the test is billable per eye when medical necessity exists. You should code with the –50 modifier on a one-line or two-line item with the –RT and –LT modifiers. Payment is 100 percent of the allowable for each eye, not a 50 percent reduction in the second eye as per surgical coding.
5. What is the difference between CPT codes 66982 and 66984? The key point to remember is that 66982 should not to be used for complications that occur during surgery. The CPT descriptor of 66982 provides the indications.
6. What is bundling? Bundling is generally referenced by the Correct Coding Initiative where payers have determined certain sets of codes that are not separately payable when performed at the same session.
7. What is upcoding? Upcoding means selecting a higher code value than was documented.
8. What’s one reason why CPT code 92136–RT might be denied payment on the remittance advice? Payment is usually denied because the ordering physician’s National Provider Identifier was not included on the claim form.
9. Define modifiers –25, –50 and –57 and provide an example of each.
- –25 should be attached to the office visit when a separately identifiable office visit is performed the same day as a minor procedure.
- –50 is attached to a procedure code when services are provided bilaterally.
- –57 is attached to the established patient office visit when determination to perform a major surgery (90 days of postoperative care) is made.
10. Can a practice have more than one fee schedule? Yes, but you can’t charge your Medicare Part B patients more than your usual and customary fee schedule.
11. What is the global period of a minor procedure? What is the global period of a major procedure? Medicare defines a minor procedure as one with a zero- or 10-day global period. Commercial payers define a minor procedure as one with zero, 10 or 15 days of postoperative care. Medicare defines a major procedure as one with 90 days of postoperative care. Commercial payers may apply 45, 60, 90 or 120 days of postoperative care.
12. Who is ultimately responsible for CPT and diagnosis code selection? The physician.
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About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.