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    Billing 101

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    Ophthalmologists and administrators rely on the knowledge and skills of their billing staff to help keep the office compliant and to assist in appropriately maximizing reimbursement.

    Some practices prefer to hire someone with little or no medical billing experience. They prefer to train new staff "in-house." Others prefer hiring someone with extensive knowledge who can "hit the ground running."

    While hiring a "veteran" can be tempting, especially for a young ophthalmologist new to billing, you could be hiring an employee who is bringing non-compliant ideas with them to your practice. To ensure that you, as well as the candidate, are on safe ground, here are few questions (and answers) to the most pressing billing issues.

    Test Their Knowledge

    1. What is the difference between a diagnosis and a procedure? Give an example of each.
    2. What documentation requirements are necessary when coding a consultation?
    3. What are the differences between the Evaluation and Management codes and the Eye codes for office visits?
    4. CPT code 99213 is paid the same by all payers. True or False
    5. How should unilateral procedures be coded?
    6. What is the full definition of 66982?
    7. What is bundling?
    8. What is upcoding?
    9. CPT code 76519-RT is denied payment on the medical explanation of benefits. Explain one reason why.
    10. Provide the definition of modifiers -25, -50, -51, -57 and give an example of each.
    11. Can a practice have more than one fee schedule? Give explanation to support your answer.
    12. Who is ultimately responsible for procedure and diagnosis code selection?

    Did You Know?

    Check your own answers against the correct ones.

    1. Both a diagnosis (ICD-9) code and procedure (CPT) code are required when filing a claim. The prospective staff should give an example where the ICD-9 correlates to procedure, such as 92083 Visual field and 365.XX glaucoma.
    2. Preferably, a written request for the consult from an appropriate referring source. (A provider with a UPIN number.) A consultant letter sent back to the referring source specifying outcome and any test or surgery recommended.
    3. All payers nationally recognize E&M (99XXX) documentation. Eye codes (92XXX) are specific by state and by payer. Some Medicare carriers have a specific Local Medical Review Policies (LMRP) with documentation requirements. Others rely on the CPT descriptor. Commercial carriers have even more varied rules.
    4. False. Payers calculate relative value units (RVUs) differently and incorporate other factors. Therefore, fee schedules vary per payer and also within sub plans of a single payer.
    5. Unilateral means the procedure is billable per eye when medical necessity exists. CPT code with -50 modifier and or a two line item with the RT and LT modifiers.
    6. See CPT descriptor. The key is this code is not to be used for complications that occur during surgery.
    7. Bundling is generally referenced by the Correct Coding Initiative (CCI) or black box edits where payers have determined certain sets of codes that are not separately payable, but bundled, when performed during the same session.
    8. Selecting a higher code value than was actually documented.
    9. Payment is usually denied because the ordering physicians UPIN number is not submitted on the claim form.
    10. Modifier -25 should be attached to the office visit when a minor procedure is performed the same day. Modifier -50 is attached to a procedure code when the services are provided bilaterally. Modifier -51 is attached to the second - fifth procedure codes when multiple procedures are performed on the patient in the same setting. Modifier -57 is attached to the office visit when determination to perform a major surgery is made.
    11. Yes. The rule is that you can't charge your Medicare patients more than your usual and customary fee schedule.
    12. The physician.

    Side Note about Medicare as Primary or Secondary Payer

    Many times we erroneously assume that if the patient is 65 or older, the claim for services should be sent to Medicare as a primary payer. The following tips will help you determine when Medicare is actually the secondary payer.

    Bill the other insurance first if:

    1. The patient is 65 or older and is covered under a spouse's employer group health plan.
    2. A retired spouse returns to work, even temporarily and gets employee health benefits that cover the patient.
    3. The patient has Railroad Retirement benefits. Send the claim to Travelers Insurance Co.
    4. The patient has Black Lung disease. The claim should be filed to the federal Department of Labor.
    5. The patient is a member of the United Mine Workers of America (UMWA). The claim should be filed to them.
    6. A retired patient returns to work, even temporarily, and gets employee health benefits.
    7. The patient has VA benefits that cover your services.
    8. The disease or injury is related to the patient's current or previous job. In all states Workers' Compensation is payment in full.
    9. The patient has an injury and also has no-fault insurance.

    Happy billing!

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    About the author: This article was based on a previous AAOE item written by Sue Vicchrilli, COT, Coding Program Manager for the American Academy of Ophthalmic Executives.