Jan. 1 coding changes—are you ready?
Excerpted from page 38 of the November/December 2020 edition of AOA Focus.
Doctors of optometry and their staff need to be prepared for substantial changes in 2021 to the coding and documentation for evaluation and management (E/M) services.
The E/M code category in the Current Procedural Terminology (CPT) code set describes the various types of patient visits. Starting Jan. 1, 2021, E/M codes will need to be selected based on what is more appropriate: medical decision-making or total time, not a patient’s history and physical.
Currently, total time may be reported by itself but only if more than 50% of the time with the patient is for coordination of care or counseling. With the new system, time can qualify on its own.
“It’s not coding by the numbers anymore,” says Rebecca Wartman, O.D., of Asheville, North Carolina, the AOA adviser to the American Medical Association CPT Editorial Panel. Doctors of optometry will still need to document what is medically necessary for patient history and the exam. “They’re just not dictating each element that needs to be in there to get paid,” Dr. Wartman says.
As Harvey Richman, O.D., of Manasquan, New Jersey, AOA’s alternate adviser to the CPT Editorial Panel, explains it: “Now we actually have to just do what we want to do—take care of the patient, find out what the diagnosis is, treat them and move on to the next patient without having to do 13 other things just to get paid. Now we get paid based on what we’re finding and what we’re doing for that specific condition.”
The changes came about after the Centers for Medicare & Medicaid Services (CMS) in 2018 proposed flattening the rate to a single payment rate for E/M visit levels 2-5 (physician and nonphysician in office-based/outpatient setting for new and established patients).
CMS also proposed to change documentation standards and develop an additional add-on code and bonus payment for the provision of primary care services. The agency argued that the changes would simplify record-keeping and reporting requirements. However, the physician community, including the AOA, pushed back because the changes would ignore physician input and the established process for setting the values for each service, which has been determined through the Relative Value Scale Update Committee (RUC) since 1991. CMS has accepted RUC recommendations on code values most of the time.
The codes themselves are created and maintained by the CPT Editorial Panel. Physician societies convinced CMS to allow the CPT panel to recommend changes instead. Those are the changes that will take effect in 2021. With Drs. Wartman and Richman as AOA advisers to the panel, doctors and their patients are represented at the highest level of the coding process. Both physicians also are members of the AOA Coding and Reimbursement Committee.
“We have seen multiple times that if we are not there [at the CPT Panel] listening, giving actual input to codes, often optometry and optometric services will be excluded,” Dr. Richman says.
The AOA also has formed solid working relationships with representatives of the American Academy of Ophthalmology and other ophthalmology specialty societies. This allows them to present eye care codes together as a united front and have a stronger force, Dr. Wartman says.
The AOA is further involved in the process because Doug Morrow, O.D., of Auburn, Indiana, chair of the AOA Coding and Reimbursement Committee, is a sitting member of the CPT Editorial Panel. However, in that position, he cannot advocate specifically for the AOA but must evaluate the validity of all CPT codes and the CPT process.
“What is important in the position I’ve gotten to is the recognition and stature it gives to the optometry profession,” Dr. Morrow says.
After the CMS initially proposed flattening the E/M rate, the AOA was invited to meet with U.S. Department of Health and Human Services Deputy Secretary Eric Hargan, J.D., to discuss the CMS proposal. During that meeting, the AOA stressed that any E/M add-on codes for providing primary care should not be specialty specific and should be open to all physician types.
The AOA also is involved in the coding process by sending out detailed RUC surveys to its members. The survey findings provide important information in valuing optometric services, Dr. Morrow says. “When we send out those surveys, it’s critically important to respond because it shows the RUC that we value the opportunity to estimate our services and estimate the time it takes to do those services,” he says.
Without input from optometric practices, it’s left up to other professions such as ophthalmology to provide the input for each code. The financial impact of the E/M changes will depend on your type of optometric practice, the types of patients and conditions you see, and how often you use E/M codes, experts say.
AOA members can get their coding questions answered through AOA Coding Today, an online, comprehensive database that contains information in real time for CPT, ICD-10 and HCPCS coding and research. Members also can ask specific coding questions through the Ask the Coding Experts resource.
An #AskAOA webinar on 2021 coding changes will take place Tuesday, Dec. 8, at 9 p.m. ET. Register now.
AOA pushing bill to stop pending Medicare payment cuts to doctors of optometry, others during COVID-19
The AOA and other leading physician organizations are pushing legislation that would halt Medicare payment cuts resulting from evaluation and management (E/M) code changes slated for Jan. 1, 2021.
Introduced by Reps. Ami Bera, M.D., D-Calif., and Larry Bucshon, M.D., R-Ind., H.R 8702, the “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020,” would keep payments at 2020 rates for the services in question for two years while the planned E/M payment increases take place. After the two-year pause, the full adjustment would be enacted.
In a letter to U.S. House members—pushed by the AOA, the American Medical Association and others—advocates appeal for stability due to the ongoing COVID-19 pandemic and note a necessity to halt any payment reductions that could inadvertently limit patient access to care or further exacerbate the financial instability of health care providers. Congressional action is needed as previous efforts from the AOA and other physician organizations have been ineffective in pushing CMS to take corrective action on this critical issue.
Diagnostic code changes
Unlike with E/M codes, diagnostic codes for 2021 only had a few changes that will affect optometric practices, including new codes for COVID-19 and vaping. While these specific codes may not be used much in optometry, applying them when applicable can be important for public health tracking, Dr. Wartman says.
Other changes include:
- H18.5—the corneal dystrophy section changes include adding right eye, left eye or bilateral eye to the code listing. Endothelial corneal dystrophy, epithelial (juvenile) corneal dystrophy, granular corneal dystrophy, lattice corneal dystrophy, macular corneal dystrophy and other inherited corneal dystrophy all added the eye-specific coding.
- H55.81—the definition was changed to add the word “deficient”: deficient saccadic eye movement, and H55.82, “deficient smooth pursuit eye movement,” was added.
- R51 and R52—minor edits were made to the headache section of the code list.
- T86.840 and T86.841—these sections dealing with corneal transplant rejection, transplant failure and transplant infection were edited to specify which eye was affected.
- Therapeutic (nonsurgical) and rehabilitative ophthalmic adverse impact codes were added for contact lens complications Y77.11 and other ophthalmic devices V77.19. Using these adverse impact codes is important to better track ocular complications that are a direct result of contact lenses. Tracking these complications will aid in combating the illegal and over-the-counter sale of contact lenses. Please be sure to use them when appropriate.
Drs. Richman and Wartman stress the importance of doctors of optometry reviewing and understanding any code changes each year. “In order to get reimbursed, you must know the coding system because third-party payers rely on us giving the appropriate diagnostic and procedural codes for their systems to come up with policy and reimbursement protocol,” Dr. Richman says.
A common misconception is that if a practice gets reimbursed, then the doctor coded appropriately, and that’s not always the case, he says. “There are a lot of policies out there that people don’t understand and wait until after they get their audit or their review or their request for money back, and then realize they made a mistake,” he says.
Appropriate coding also benefits your patients and the entire profession, Dr. Morrow says.
“If doctors of optometry understand the coding, they know whether it’s medical decision-making that they’re doing or vision care, and it allows the doctor to appropriately direct the care and the billing for the whole system,” he says.
Find coding and billing education at EyeLearn Professional Development Hub, the AOA’s member-exclusive, centralized education portal.
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.