• How Would You Bill? Test Your Coding Competency

    Physicians have ultimate responsibility for CPT and diagnosis code selection, as well as chart documentation. Test your billing knowledge with these three cases from the American Academy of Ophthalmic Executives.

    Case Number 1

    A-73-year-old woman with Fuchs’ dystrophy who had previous bilateral penetrating keratoplasties (PKs) was scheduled for a repeat procedure in her right eye. During the preoperative exam, the ophthalmologist found a minimal cataract. The patient had surgery, and during the global period, she felt that her vision was “all of a sudden going bad.” At that time, the ophthalmologist discovered that the cataract was now mature and required a B-scan to view the retina properly. S/he then scheduled the patient for cataract surgery.  

    How to submit: If the mature cataract is unrelated to the primary procedure, bill an exam with modifier -24 indicating it as such. Make sure that the submitted documentation and diagnosis reflect only the cataract. You should also submit CPT code 76513 B-Scan with no additional modifier and link the diagnosis of mature cataract to the test.

    If you used dye for the mature cataract, submit 66982 Complex cataract surgery and append CPT code modifier -79 indicating this was not related to the actual PK procedure. In order for the procedure to qualify as “complex,” all three local coverage determination policies require the use of dye for a mature cataract. If your Medicare Administrative Contractor does not have a policy, refer to one that does. Other payers may have different guidelines, so be sure you follow the payer’s requirements.

    Case Number 2

    A new commercial patient presented with upper-eyelid drooping that has persisted over the past two years. During this time, the patient has needed to hold both lids open in order to read a newspaper or book and has experienced an increase in headaches due to eye strain. The ophthalmologist documented a complete review of systems, plus past, family and social histories and performed 11 exam elements. The physician also ordered ocular photographs and a visual field, then scheduled the patient for bilateral upper-lid blepharoplasty.

    How to submit: Submit CPT codes 99203 or 92002 for the exam and determine whether or not your payer has requirements for billing an eye visit code. Because this was not a comprehensive exam, you should not submit CPT code 92004.

    In addition, you should submit CPT code 92285 External ocular photography along with the exam and follow the payer’s testing requirements (whether visual fields or photos, or both). Find state-specific MAC testing requirements on the Academy website.

    Note: For new patient exams, you must complete all three components when using an evaluation and management code. In this case, the ophthalmologist took a comprehensive history due to four HPI, complete ROS and complete PFHS. Medical decision-making was moderate complexity as a major procedure was necessary. However, because the ophthalmologist performed only 11 exam elements, this reduced the exam to problem detailed.

    Code Decision-Making Examination History*
    99201 Straightforward Problem focused Problem focused
    99202 Straightforward Expanded Expanded
    99203 Low complexity Detailed Detailed
    99204 Moderate complexity Comprehensive Comprehensive
    99205 High complexity Comprehensive Comprehensive
    *E&M codes involve two aspects of history. For more information, see “Past, Family and Social History” and “The Chief Complaint and History of Present Illness.”

    Case Number 3 

    A Medicare Part B patient presented for a bilateral glaucoma evaluation and stated no changes in vision since his/her last exam. The patient had a history of diabetes and cataracts. The glaucoma evaluation included testing of visual acuity, pupils and iris, gross visual fields, ocular adnexa and intraocular pressure. The ophthalmologist told the patient to follow up in three months, continue current medications and call back if s/he noted any changes or difficulty with the medications.  

    How to submit: The exam qualifies for established patient exam 99213 or 92012 for this established patient visit. The history and exam components were both problem focused, and the medical decision-making was straightforward. Although the level of service may not have changed, you should always document a thorough history of the present illness. In addition, the ophthalmologist should have noted how well the patient tolerated his/her medications and the date of the previous exam.

    Code Decision-Making Examination History
    99221 N/A N/A N/A
    99212 Straightforward Problem focused Problem focused
    99213 Low complexity Expanded Expanded
    99214 Moderate complexity Detailed Detailed
    99215 High complexity Comprehensive Comprehensive

    Because you can document the status of three chronic or inactive diseases for established patients, the ophthalmologist should also have expanded his/her documentation to include both diabetes and cataracts.

    (Updated April 12 to correct the code in case 3.)

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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.