With payer rules in constant flux, you need to stay current so that your claims are paid right the first time. How up to date is your ophthalmic coding knowledge? Test yourself with these five questions from the American Academy of Ophthalmic Executives’ 2015 Codequest course.
1. When hiring a new physician for your practice, it’s best to first check with the Office of Inspector General.
True. If you’re adding a licensed professional to a practice, verify his or her status with the OIG’s exclusions database. A search will show you whether he or she was part of any settlement agreements with the OIG or excluded from participating in any federal health care programs.
2. A Medicare Advantage Plan patient is scheduled for bilateral blepharoplasty. You should obtain an Advance Beneficiary Notice and append modifier GA to the surgery just as you would for a Medicare Part B patient.
False. Medicare Part B is the only payer that can use an ABN form. A Medicare Advantage Plan needs to follow its thirdparty administrator requirements such as prior authorization.
3. What isn’t paid by Medicare Part B when a patient is treated in a skilled nursing facility?
Medicare Part B doesn’t pay for postoperative cataract glasses, the technical component of tests and any drugs that are injected. Although stays in a skilled nursing facility are usually limited to 20 days, if a service is necessary, contact the facility for reimbursement. Be sure to get this agreement in writing; they are not required to reimburse you.
4. A retina specialist refers a patient to the glaucoma specialist in the same office. How should the latter bill the patient’s commercial payer?
A. The appropriate level of consult code
B. A new patient E&M or Eye code
C. An established patient E&M or Eye code
C. The patient is established under the practice’s tax ID.
5. Discontinued surgical procedures have a global period.
False. When a physician must discontinue a procedure due to extenuating circumstances (or those that threaten the patient’s wellbeing), you can append modifier 53 to that case. In order to determine the payment, payers will also ask for an operative report. By appending this modifier, no postoperative period begins. However, be sure to see if there is an existing CPT code for what was performed.
Tip: Visit www.aao.org/codequest to see when the next Codequest coding course will come to your area.
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About the author: 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 Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series.