Last month, YO Info looked at when and how ophthalmologists should bill for testing services so that you can pass an audit. Here are some additional tips and cases to help you along the way.
1. Check whether you must always be onsite when ancillary staff perform tests.
For Medicare patients, CMS recognizes three levels of supervision. Find these supervision levels in the latest fee schedule and in the Academy’s 2017 Ophthalmic Coding: Learn to Code the Essentials and Coding Coach:
- General: A physician does not need to be onsite; however, the test is performed under a physician’s overall direction and control.
- Example: CPT codes 92134 Retina OCT, 92083 Visual field
- Direct: A physician must be in the office suite and readily available if necessary.
- Example: CPT codes 92235 Fluorescein angiography, 95930 Visual evoked potential
- Personal: A physician must be in the room while the test is performed.
- Example: CPT code 92265 Needle oculoelectromyography
Many commercial payers only recognize direct supervision, which requires a physician to be onsite for all delegated testing services. Tests that do not include supervision language are based on physician work; you cannot delegate them to staff.
Auditors now routinely ask for additional practice information to confirm whether or not practices meet these supervision guidelines.
2. Do not bill the technical and professional components separately if performed on different days.
When your practice owns the equipment and provides the interpretation, bill the test without breaking out each component. Only append the eye modifier, if applicable.
In addition, you do not have to wait to see the patient to document the professional component of the test. You can document this component as soon after the test as possible and provide the patient with the results by phone, unless another exam is medically necessary.
When another practice that does not own the equipment asks you to perform a specific test, bill only the technical component. The ordering physician will bill for the professional component. If the patient has commercial insurance, note that such payers may not recognize the technical component. If that’s the case, communicate with the other practice to decide who will bill for the service as a whole.
3. Avoid billing for reduced services when you perform an inherently bilateral test on only one eye.
Unless specifically stated by a payer in writing, bill the test without modifier -52 Reduced services. Appending the eye modifiers will result in a denial or request for additional information.
4. See if you need a modifier for the testing service.
Each Medicare Administrative Contractor has a fee schedule and payment indicator unique for that jurisdiction. To see if you need a modifier, look up the bilateral indicators for your contractor. You can find these indicators on each MAC fee schedule page.
For example, here are the bilateral indicators and their definitions for all Medicare contractors:
- A 2 indicates that a 150 percent payment adjustment for a bilateral procedure does not apply. The service is considered inherently bilateral, so it would be inappropriate for you to use modifier -50 or -RT, -LT.
- Example: CPT codes 92020 Gonioscopy, 92133 Optic nerve OCT both have this indicator. See also case 1, below.
- Audit note: If you add modifier -50 despite the payment indicator, your MAC would deny the claim and could flag future claims.
- A 3 indicates that the usual payment adjustment for bilateral procedures does not apply. You can bill the service unilaterally when medically necessary.
- Example: 92225 Extended ophthalmoscopy, 92136 -26 A-scan for IOL professional component both have this indicator. See also case 2, below.
- Be sure that both eyes have pathology when billing bilaterally.
Case 1: Monitoring posterior vitreous detachment and epiretinal membrane in one eye
A new patient complains of gradual distortion in both distance and near vision in the left eye. After performing a comprehensive history exam, the physician orders a retinal OCT of the left eye and finds a posterior vitreous detachment and epiretinal membrane. She plans to monitor the patient and have him return in three months or sooner if changes occur.
How to bill it:
- Use E&M 99203 or Eye visit code 92004 depending on the payer. Do not append a modifier to the exam.
- Use CPT code 92134 Retina OCT. This code is inherently bilateral; therefore, do not append a modifier even though you performed the test only on the left eye.
Case 2: Lasering a retinal tear after posterior vitreous detachment
A Medicare patient returns for a three-week follow-up for posterior vitreous detachment in the right eye. She has no visual-field deficit, but floaters continue to occur. The physician conducts a detailed examination, draws and labels the changes, and diagnoses a posterior vitreous detachment and retinal tear. He then performs a prophylactic laser the same day, after the patient provides consent, and plans to check the patient again in one week.
How to bill it:
- Use Eye visit code 92014, as it has a higher allowable than E&M 99214 for Medicare Part B. Append modifier -57 to the exam indicating the decision for a major surgery, performed the same day as the exam.
- Use CPT code 92226 Subsequent ophthalmoscopy. You’ll need to include your evidence and drawing of the change in pathology. Some payers may have requirements regarding the drawing. It’s best to always check local coverage determinations and commercial policies. For example, Palmetto GBA (MAC) requires that the sketch be a minimum of 4 inches; however, First Coast (MAC) does not have such a requirement. Because this code is considered unilateral, append modifier –LT.
- Use CPT code 67145 Retinal detachment prophylaxis laser and append modifier –LT.
For more information and helpful tips about testing services, check out these Academy coding resources:
If you have additional coding questions, email email@example.com.
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.