Exam discounts and foreign-body removal
By Walt Whitley, O.D., Jason Miller, O.D., and Charles Brownlow, O.D., AOAExcelTM Medical Records consultants
In this edition of Ask the Codeheads, we answer questions from colleagues across the country about prompt-pay discounts and billing for foreign body removal. If you have a billing and coding question of your own, email us.
Occasional discounts are OK for any reason, as long as they don't create a pattern.
Q. I recently heard practices in surrounding areas were offering certain discounts on their exams. Are prompt-pay discounts legal?
The only acceptable discount is a prompt-pay discount offered to all patients, even if they have insurance. Most payers understand the acceptability of prompt-pay discounts, while their contracts often require doctors to bill them using their usual fees. This effectively prohibits doctors from providing discounts to patients simply because they are private pay.
It is understood that providing discounts to patients without insurance essentially creates a new usual fee from which payers will then take their discounts. Prompt-pay discounts must be given in exchange for payment on the same day of service. The discount should not be more than 20 percent of the usual fee. It may be for services, materials or both.
Medicare's policy is to pay the lesser of the doctor's usual charge or the Medicare Fee Schedule amount. Most insurers believe "usual" equates to the charge you would bill to a private-pay patient.
Occasional discounts are OK for any reason, as long as they don't create a pattern. For example, a doctor can provide a discount of up to 100 percent in special circumstances, such as for clergy, good friends or the indigent. It is dangerous, however, to provide discounts for a significant percentage of your practice unless such discounts comply with the rules of prompt-pay discounts (sometimes called cash discounts or day-of-service discounts). The significant percentage is believed to be close to 35 percent of the total practice.
Q. Can I bill an office visit 99213 with superficial conjunctival foreign body removal (65205)? If 99213 can be billed, should I add a modifier?
If the reason for the visit was something other than the finding of or subjective complaints associated with that foreign body, then yes. The surgical code, 65205, includes the finding of the foreign body and is reimbursed at a higher rate because of that.
If the patient visits for a different reason, then billing a 99xxx code or 92xxx code with a different diagnosis and attaching modifier 25 would be appropriate. Modifier 25 = Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.
You may need to indicate that on the day you performed a procedure or service identified by a CPT code, the patient's condition required a significant, separately identifiable evaluation & management (E/M) service above and beyond the other service provided or the usual preoperative and postoperative care associated with the procedure performed.
A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.
The E/M service may be prompted by the symptom or condition for which the procedure or service was provided. As such, different diagnoses are not required for reporting E/M services on the same date. You can report this circumstance by adding modifier 25 to the appropriate level of E/M service.
But please note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.