Each year, diagnostic code changes and updated documentation requirements can have physicians’ heads spinning. The Academy has identified three issues young ophthalmologists need to be aware of in 2019:
- Evaluation and management (E/M or E&M) documentation guidelines
- New diagnostic (ICD-10) codes
- Electroretinography (ERG) code updates
These changes, often issued by the Centers for Medicare and Medicaid Services (CMS), can impact an ophthalmologist’s daily practice and affect how a practice get its claims paid.
E/M Documentation Guidelines
CMS’ changes impact three situations for documentation using E/M codes. These changes do not impact the eye visit codes.
- Redocumenting patient history. Physicians are no longer required to redocument the chief complaint or history that their staff or technicians have already documented if the physician determines that this information is sufficient. Instead, physicians can indicate that they have reviewed and verified the information already documented. This impacts both new and established patient exams. Although it’s not a requirement, the change was designed to ease the documentation burden for physicians.
- Home visits. Physicians making home visits to beneficiaries are no longer required to indicate the medical necessity for why the patient receives care at home and not in a medical office. CMS further states that patients do not need to be confined to their homes to get this service. Home visits are submitted with CPT codes 99341-99350.
- Medical student and resident exam. When providing services at a teaching hospital, physicians are no longer required to redocument medical students’ or residents’ exams or medical decision-making. Physicians are still required to perform key elements of the exam and review the students’ medical decision-making and correct any errors. You must make sure to sign and date any documentation the medical student provides and attest the note as the attending physician.
New Diagnostic (ICD-10) Codes
Updates went into effect on Oct. 1, 2018, ICD-10 that added three alpha-characters for specific diagnoses:
- A in the sixth position represents right eye, upper and lower eyelids
- B in the sixth position represents left eye, upper and lower eyelids
- C in the sixth position represents bilateral, upper and lower eyelids.
ICD-10 was created to clarify what is being treated. However, these new characters currently impact a limited number of diagnoses.
All three characters are available for unspecified, cicatricial, mechanical and paralytic lagophthalmos. For example, for cicatricial lagophthalmos, the codes are:
- H02.21A Cicatricial lagophthalmos right eye, upper and lower eyelids
- H02.21B Cicatricial lagophthalmos left eye, upper and lower eyelids
- H02.21C Cicatricial lagophthalmos, bilateral, upper and lower eyelids
Only A and B are options for reporting unspecified, ulcerative and squamous blepharitis. For example, for ulcerative blepharitis, the codes are:
- H01.01A Ulcerative blepharitis, right eye, upper and lower lids
- H01.01B Ulcerative blepharitis, left eye, upper and lower lids
For a complete list of ICD-10 codes, access the Academy’s decision trees at aao.org/ICD10.
Electroretinography Code Updates
The single CPT code 92275 ERG was deleted and replaced with three new codes: 92273, 92274 and 0509T. The change was intended to distinguish between the different types of ERG testing used.
- CPT code 92273 ERG with interpretation and report; full field (i.e., ffERG, flash ERG, Ganzfeld ERG): The typical allowable is $138 with the technical component averaging $100. This is due to the length of time involved.
- CPT code 92274 ERG with interpretation and report; multifocal (mfERG): The typical allowable is $93.
- Category III code 0509T ERG with interpretation and report, pattern (PERG): It was created specifically for reporting this technology because it is significantly different from the historical ERG code.
Unlike other Category III codes, relative value units (RVUs) have been assigned with the typical allowable of $82.
There are some key points to remember when billing with new codes:
- Commercial payers may update testing service codes on a fiscal rather than calendar year. So payers may not recognize them at the beginning of the year.
- Category III code coverage is determined by each payer. Before billing, verify the coverage.
- Consider using an advance beneficiary notice (ABN) for Medicare Part B beneficiaries until you have confirmation of coverage.
- When a physician delegates tests to ancillary staff, be sure your order for the test is on file.
- Like all testing, 99211 (E/M code for an established patient visit) is bundled into the ERG codes and not separately billable. Note: Exams and tests are typically allowed on the same day. Some commercial payers may limit what tests can be performed on the same day as another service.