AOA experts answer coding questions
Consider this scenario: A patient comes in with a complaint that something flew into his eye. The OD finds a foreign body in the eye—but isn’t sure how to bill for it.
Know your plans-and how to present them to the patient.
How would coding experts from AOA's Third Party Center resolve this?
Rebecca Wartman, O.D., Douglas Morrow, O.D., and Harvey Richman, O.D., fielded queries such as this during a continuing education session, "Ask the AOA Coding Experts: Top 10 Questions," at Optometry's Meeting® on June 27.
Here are some highlights from the session:
Question: How do I bill for foreign bodies? I heard someone once say that you can't bill an office visit—is that true?
Answer: The OD might legitimately use evaluation and management codes or general ophthalmological service codes to bill for foreign body removal from the eye. In the event this is a new patient and if the patient comes in with vague complaints like red eye and no history of an injury, yet a foreign body is found, the visit may qualify for an office visit billing. You would file an office visit code using a 25 modifier (separate evaluation and management service, same day as procedure). The documentation must be very clear for the chief complaint and history of the complaint. But, if the patient has a clear history of a foreign body injury, the provider can only bill a foreign body removal code without an office visit code.
Question: I keep getting denials from Medicare for submission of post-operative care for a second eye cataract. What am I doing wrong?
Answer: ODs must ensure that their billing, plus any information on the post-op and transfer of care of a patient, matches up with the surgeon who operated on their patient.
Communication with both the surgeon and the patient is critical, the experts said. Patients must understand the exchange of care process—and should be given choices for post-operative care.
Question: Is there any way to incorporate refraction and contact lens exams into my eye exam fee if insurance isn't covering these services?
Answer: Initially, the answer is no, but most third party payers already do pay additionally for this, including vision plans and some medical plans.
Not all plans are compliant with the Health Insurance Portability and Accountability Act, the federal rules governing insurance. That's a persistent problem. Some carriers pay for general ophthalmologic and even evaluation and management codes inappropriately to include refraction. HIPAA requires carriers to observe standard code sets such as Current Procedural Terminology (CPT). CPT specifically states that the services described by the refraction code are not part of a general ophthalmologic examination.
Payers can have coverage and payment policies that link these services, but can't require you to miscode the services to bill them.
While Medicaid and Medicare managed care plans usually cover the refractive service, traditional Medicare does not. Contact lens evaluation fees are also occasionally reimbursed through some private payers and often through vision plans as an additional procedure. Two health care procedure codes (S-Codes) for routine ophthalmologic exams include refraction for new and established patients. However, there's no set valuation on these codes, and insurers are free to interpret and reimburse for them at will.
The bottom line: Just because a patient has insurance doesn't mean a procedure is covered. And if it is not covered, it may be the patient's responsibility. Know your plans—and how to present them to the patient.
Download the "Ask the AOA Coding Experts: Top 10 Questions" presentation at this link.