Don’t leave money on the table.
During residency and fellowship, you worked hard to learn everything you could to learn medicine, ophthalmology, and surgery to take the best care of your patients. You were a salaried employee — you made the same amount of money if you saw three patients on call or if you saw 13.
But now, any procedures you do, patients you see, tests you run and don’t code or bill correctly is money that cannot go to cover your overhead, pay for your new OCT machine, or for your children’s college fund.
This article will cover some key coding tips that are essential for you to know. The most important tip: do not bill fraudulently — bill only for the work you did. You have worked hard to get where you are, you should be paid appropriately for the work that you do.
Key point No. 1: Do not code “probable,” “suspected,” “possible” or “rule out” conditions. You should code the sign or symptom or any confirmed diagnosis. Exception: ICD-10 code for glaucoma suspect (low risk: H40.01x or high risk: H40.02x). See the Academy guide on choosing the right ICD-10 code for glaucoma.
Eye vs E/M Code
The Academy has published great tips for coding your visits. View information on how to bill E/M codes (992xx).
Key point No. 2: Any test with a CPT code current or past for which you receive(d) separate payment does not count in the amount and/or complexity of Data Medical Decision Making (MDM) category. For example, if you order a head CT scan, that counts as ordering a test; ordering an OCT, however, does not count (because you will bill for the OCT).
Key point No. 3: for Eye Visit codes (920xx), always document a chief complaint, a general medical observation of your patient, and initiation or continuation of diagnostic and treatment programs. You cannot bill an eye code without these!
Key point No. 4: Each test you order requires:
- Date of service
- Name of the test(s)
- Medical necessity reflected in the chart note with a Medically necessary diagnosis
- Eye(s) are being tested
- Physician legible or secure electronic signature
If you perform the test (gonioscopy, sensorimotor, extended ophthalmoscopy, etc), you do not need an order, but you still need to document your interpretation.
Key point No. 5: Know which tests you can bill in the same encounter. Fundus photos + extended ophthalmoscopy? Cannot bill for both—they are mutually exclusive. Fundus photo + OCT macula? Only bill for the one that contributes the most to your medical decision making (they are bundled). See figures 1 and 2 for an excellent reference chart.
Key point No. 6: Know what you can bill for during your examination. Don’t forget to document your impression/interpretation and report. When medically necessary, these and other tests are billable during the global post-operative period whether related or unrelated to the surgery.
- Gonioscopy (92020)
- Payment is inherently bilateral
- Whether you perform on one eye or both, payment is the same.
- Supervision rules do not apply as this is typically performed by a physician
- CPT description includes (separate procedure), some payers may not pay if performed with other exams and tests
- Corneal Pachymetry (76514)
- Payment is inherently bilateral
- Covered on a one-time basis when performed on glaucoma patients.
- Sensorimotor exam (92060): You must document multiple measurements of ocular alignment in different fields of gaze and/or at different distances. You also need to document a sensory test, such as stereo rings, stereo fly, and/or the Worth 4-dot test.
- Extended Ophthalmoscopy, with scleral depression (92201): “With retinal drawing and scleral depression of peripheral retinal disease” (unilateral or bilateral)
- Extended Ophthalmoscopy (92202): “With drawing of optic nerve or macula” (unilateral or bilateral)
- Refraction (92015): Check your payer policies on refraction; some practices will charge patients if their insurance does not cover it.
- External ocular photography (92285): Check payer policies for diagnosis coverage.
Key point No. 7: You cannot bill for tests that have “standing orders”. For example, if a patient comes in as a referral from the optometrist for suspicion of glaucoma, you cannot bill for the tests if your technicians automatically get a visual field, OCT of the nerve, and pachymetry. To bill for these tests, the physician should examine the patient first then order the appropriate tests. Suggested workflow: For these patients, perform your gonioscopy, take a peek at the nerves un-dilated, then order/perform your tests.
By knowing these key points, you are on your way to getting paid appropriately for your work.
Practice Management for YOs
||About the author: Evan Silverstein, MD, is a pediatric ophthalmologist, assistant professor of ophthalmology and associate residency program director at Virginia Commonwealth University in Richmond, Va. He is chair of the YO Info editorial board.