3 coding questions cracked
Excerpted from page 49 of the September 2023 edition of AOA Focus.
The AOA’s coding experts offer guidance to support doctors and staff in providing the best possible patient care while ensuring accurate reimbursements are received.
Here are some recent questions posed to the experts and their answers.
If a doctor of optometry participates in Medicare but is not a supplier of durable medical equipment (DMEPOS), will they be able to bill Medicare for contact lenses and glasses after cataract surgery?
Before you can bill Medicare for post-surgery eyewear, your practice must enroll and pay the registration fee as a DMEPOS supplier.
For the purposes of the MIPS exemption, does the low-volume threshold also apply to Medicare Advantage patients?
No, the low-volume threshold only applies to Medicare Part B patients and allowed charges.
Does Medicare allow a doctor of optometry to bill fundus photos and an optical coherence tomography on the same day for two different diagnoses?
Medicare rules (per the Correct Coding Initiative) do not allow for billing an optical coherence tomography and photo on the same day, even with separate diagnoses. However, under exceptional circumstances, a workaround is possible. Per CMS, modifier -59 should be used to “indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day.” However, “documentation must support a different session, different procedure, or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.” Staging on different visits is the best way to accomplish this testing and get paid.
Ask the coding experts
If you have any questions regarding Medical Records and Coding, please submit them by using the Coding Experts Submission Form and one of our coding experts will be in contact with you.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2023, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.
The answer to this question, and more, from the AOA’s coding experts.