How to pick the right benefit notice and bill for medications

By Walt Whitley, O.D., Jason Miller, O.D., and Charles Brownlow, O.D., AOAExcelTM Medical Records consultants

This month, we review common questions from colleagues across the country. These questions relate to issues facing numerous practices, so you are not alone.

"Non-covered items or services will be the responsibility of the patient."

Using the right notice

Q. Can you tell me more about the Advance Beneficiary Notice and how it differs from the Notice of Exclusions of Medicare Benefits? Where can I get one, and when should I use it?

The Advance Beneficiary Notice (ABN) can be used any time you provide a service to a patient (fields, photos, imaging, etc.) and are unsure whether an insurer will cover it. For example, the insurer might say the procedure isn't covered when combined with certain diagnosis codes. In this case, have the patient sign the ABN before the test is done, agreeing to pay for the test in the event the insurer does not. The CMS offers more details.

The Notice of Exclusions from Medicare Benefits (NEMB) addresses items and services for which Medicare will not pay. These non-covered items or services will be the responsibility of the patient. The purpose of this notice is to help patients make an informed choice about whether they want to receive these items or services, knowing they will have to pay for them.

Refraction is the most common example of a possible use of the NEMB. You should help the patient understand refraction is an important service even though it is not covered by Medicare. Another example: patients electing an advanced technology intraocular lens (IOL), which is an elective procedure to reduce dependency on glasses or contact lenses. The standard cataract surgery is covered by Medicare, but the extra charges for the advanced IOL are not. The NEMB would be used for those extra charges.

Proper billing for high-risk medications

Q. If we have a patient on Plaquenil, what is the best CPT and ICD-9 to bill for visits and additional testing?

In 2011, the American Academy of Ophthalmology revised the recommended guidelines for patients using chloroquine (CQ) and hydroxychloroquine (Plaquenil). The updated testing includes a dilated fundus examination to establish a baseline and to rule out maculopathy. Fundus photography also can be considered for documentation. Recommendations also include performing an automated 10-2 visual field in addition to one or all of the following:

  • Spectral domain optical coherence tomography (SD-OCT),
  • Fundus autofluorescence (FAF), or
  • Multifocal electroretinogram (mfERG) if available.

The question that remains is how to properly bill for this.

First, screening tests are never covered alone, so it is important to establish and document medical necessity. The "reason for the visit" is to diagnose and document any changes that may occur with the use of high-risk medications. Use the appropriate CPT codes that most accurately describe the examination (either a 99XXX or 92XXX) with the corresponding ICD-9 code that best describes the condition you are evaluating. A dilated fundus examination is used to detect and document any damage to the optic nerve, macula or retina along with any baseline testing. Fundus photography (92250) is used to establish a baseline to compare for future changes to the macula/retina, while SD-OCT (92134) is used to document changes in the affected area.

The three most-common ICD-9 codes used for patients on high-risk medications such as plaquenil include:

  1. The code for the condition (e.g. 714.0, rheumatoid arthritis with Plaquenil),
  2. V58.69 (long-term use of high-risk medications), and
  3. The E-code for the medication (E931.4 for Plaquenil).

E-codes are supplemental codes that capture the external cause of injury or poisoning or the intent and the place where the event occurred. They are intended to provide data for injury research and prevention strategies and are never used as a primary diagnosis.

Ask a question, join a webinar

If you have billing and coding questions, e-mail them to us at And join our October webinar, when we will discuss "Updates on HIPAA and ICD-10" and answer questions from the audience. We hope to "see" you there!

September 30, 2013

comments powered by Disqus