Ophthalmology Coding: Raise Your Eye-Q. Nancy Clark, CPC, COC, CPB, CPMA, CPC-I

Transcription

1 Ophthalmology Coding: Raise Your Eye-Q Nancy Clark, CPC, COC, CPB, CPMA, CPC-I 1

2 Disclaimer The information in this presentation was current at the time the presentation was compiled. Always consult CPT, ICD-9-CM, ICD-10- CM, CMS and commercial payers for specific guidance in reporting services. This presentation is designed to provide accurate information in regard to the subject matter covered. The information includes both reporting and interpretation of materials in various publications, as well as interpretation of policies of various organizations. Every reasonable effort has been made to ensure the accuracy of this information. The duplication of this presentation, all or in part, without the express permission of the presenter, is strictly prohibited. 2

3 Agenda Eye Exam Codes vs. E/M Codes Diagnostic Testing Procedures Surgical Procedures 2017 ICD-10 Updates 3

4 Eye Exam Codes New Patients Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, one or more visits Established Patients Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, one or more visits 4

5 Intermediate Intermediate vs. Comprehensive (92002 or 92012) Evaluation of a new or existing condition Not necessarily relating to the primary diagnosis History General Medical Examination External ocular and adnexal exam Other diagnostic procedures as indicated May include mydriasis for ophthalmoscopy Eye Exams Comprehensive (92004 or 92014) General evaluation of the complete visual system Does not need to be performed at one session History General Medical Examination External Examination Ophthalmoscopic Examination Gross Visual Fields Basic Sensorimotor Evaluation Optional Components, as Indicated: Biomicroscopy Exam with cycloplegia or mydriasis Tonometry Initiation of diagnostic and treatment programs Prescription of medication Arranging for special ophthalmological, diagnostic or treatment services Consultations Laboratory procedures Radiological services Carriers may add additional requirements or exceptions Continued... 5

6 Examples Intermediate History, external examination, ophthalmoscopy, biomicroscopy for an acute complicated condition (e.g. iritis) not requiring comprehensive ophthalmological services Interval history, external examination, ophthalmoscopy, biomicroscopy and tonometry in established patient with known cataract not requiring comprehensive ophthalmological services Comprehensive Diagnosis and treatment of a patient with symptoms indicating possible disease of the visual system, such as Glaucoma Cataract Retinal disease, or To rule out disease of the visual system New or established patient Reference CPT(R) Professional

7 Bundled Services Slit lamp exam Keratometry Routine ophthalmoscopy Retinoscopy Tonometry Motor evaluation Compare to E/M Service.. 7

8 E/M Codes with 1997 Eye Exam Elements History Exam Test visual acuity (Does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) Exam (Continued) Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation)and nerve fiber layer Posterior segments including retina and vessels (e.g., exudates and hemorrhages) Brief assessment of mental status including Orientation to time, place and person Mood and affect (e.g., depression, anxiety, agitation) Exam Level Problem Focused 1-5 elements Expanded Problem Focused 6 + elements Detailed 9 + elements Comprehensive Perform and document Every element in the eye exam category Perform and document at least 1 element in Neurological/Psychiatric Medical Decision Making 8

9 Considerations for Using E/M vs. an Eye Exam What does the documentation support? Diagnosis specific regulations For certain insurance companies eyelid and adnexa diagnoses may not be considered medically necessary for some components of eye exam Know your carriers requirements and patients insurance Routine or Medical Frequency Allowed Very detailed consultation/patient visit may support E/M 9

10 Routine Eye Exams Most carriers use CPT with Z codes Z01.00, Encounter for examination of eyes and vision without abnormal findings Z01.01, Encounter for examination of eyes and vision with abnormal findings Use additional code to identify abnormal findings Alternatively, Medicaid and some carriers use S0620 Routine ophthalmological examination including refraction; new patient S0621 Routine ophthalmological examination including refraction; established patient These codes include 92015, Determination of refractive state Medicare does not reimburse for routine (screening) exams Note signs/symptoms/disease processes 10

11 Diagnostic Testing Procedures Important Reimbursement Concepts Multiple Procedure Payment Reductions (MPPR) Bilateral Procedures Extended Ophthalmoscopy Fluorescein and Indocyanine Green Angiography Fundus Photography Ophthalmic A and B Scans Visual Field Testing 11

12 Multiple Procedure Payment Reductions (MPPR) Identify appropriate reductions Reduction to 80% of allowed fee schedule for the technical component (TC) of certain diagnostic ophthalmology procedures Applies to subsequent procedures when multiple procedures are furnished to the same patient on the same date of service Does not apply to the Professional Component (PC) Identify using MPFS Payment Policy Indicators multiple surgery column 7 = Diagnostic ophthalmology services subject to the MPPR methodology 0 = No payment adjustment rules for multiple procedures apply 12

13 Multiple Procedure Payment Reductions Example CPT Code CPT Code Total Payment Before Reduction Total Payment After Reduction Payment Calculation PC $46.00 $23.00 $69.00 $69.00 No Reduction TC $92.00 $53.00 $ $ $ (80% x $53.00) Global $ $76.00 $ $ $ $ (80% x $53.00)

14 Medicare Physician Fee Schedule Payment Policy Indicators

15 Bilateral Procedures Identify appropriate reimbursement for bilateral procedures Use MPFS Bilateral Surgery Indicator 1= Payment is 150% fee schedule for bilateral. 2= No increase. Procedure is already bilateral. 3= Each eye is coded independently at 100% of FS. Bilateral = 200% of FS 0= Payment adjustment for bilateral does not apply. 15

16 Extended Ophthalmoscopy CPT Codes and Ophthalmoscopy, extended, with retinal drawing (e.g. for retinal detachment, melanoma), with interpretation and report; initial Subsequent Routine ophthalmoscopy is part of general and special ophthalmologic services and is not reported separately Modifier 25 usage for significantly separate procedure Unilateral procedure Reimbursed at 100% for each eye No MPPR reduction Documentation Requirements Retinal drawings Appropriate size, color, detail Documentation in the patient s medical record for a diagnosis of glaucoma includes A separate detailed drawing of the optic nerve Documentation of cupping, disc rim, pallor, and slope Documentation of any surrounding pathology around the optic nerve. Medical necessity for each eye examined Document that the pupil was dilated and what drug was used All findings and a plan of action should be documented in notes Continued... 16

17 Extended Ophthalmoscopy Indications and Limitations Indications Medically reasonable and necessary: Neoplasm Trauma Abnormalities of the macula, retina or choroid Specified other acute symptoms & chronic conditions Review LCD s, available for Palmetto, CGS, NGS and First Coast Limitations Should not be routinely used on both eyes of every patient on all visits. Routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable Not reimbursable within the global period of ophthalmic surgery unless distinct Not performed with other testing (i.e. fundus photography, flourescein angiography) 17

18 Fluorescein Angiography CPT Codes Fluorescein angioscopy with interpretation and report Fluorescein Angiography (includes multiframe imaging) with interpretation and report Taking photos of inner eye vessels using fluorescein dye Frequency as often as every 8 weeks to assist in management of retinopathy Unilateral procedure Reimbursed at 100% for each eye Subject to MPPR reduction Indications and Guidelines Initial evaluation of a patient with abnormal findings of the fundus/retina Patients presenting with sudden vision loss Evaluation of patients with Diabetic retinopathy Chorioretinitis, chorioretinal scars, dystrophies, hemorrhage, rupture or detachment Known retinal or macular disorders Ocular tumors, visual loss in systemic disease, and optic disc disease Written report Review LCD s, available at First Coast, CGS, Palmetto 18

19 Indocyanine Green Angiography (ICG) CPT Code Indocyanine-Green Angiography (includes multiframe imagine) with interpretation and report Taking photos of eye using ICG dye Frequency is dependent on performance of Fluorescein Angiography and disease process Unilateral procedure Reimbursed at 100% for each eye Subject to MPPR reduction Indications and Guidelines A valuable diagnostic adjunct to fluorescein angiography in the evaluation of Retinal neovascularization Choroid neovascularization Serous detachment of retinal pigment epithelium Hemorrhagic detachment of retinal pigment epithelium Retinal hemorrhage Written report Review LCD s available at First Coast, CGS, Palmetto Continued... 19

20 Fluorescein and ICG Angiography Limitations ICG angiography must be performed under the direct supervision of a physician when done by a nonphysician practitioner Some state law excludes optometrists from performing invasive procedures, including ICG New Jersey and New York State Contraindicated for patients allergic to iodine Not medically necessary for evaluation of background diabetic retinopathy 20

21 Fundus Photography CPT Code Fundus photography with interpretation and report Bundled with 92240, ICG Angiography Bilateral procedure, no additional reimbursement May use modifier 52 for one eye Subject to MPPR Review LCD s, available at First Coast, NGS, CGS Indications and Guidelines Use of a retinal camera to photograph regions of the vitreous, retina, choroid, and optic nerve (posterior segment) Documents changes in baseline retinal findings and track disease progression Images may be either photographic or digital and become part of the patient s permanent record. Usually taken through a dilated pupil A single series of photographs will be reimbursed where clinically indicated 21

22 Ophthalmic A and B Scans CPT Codes Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter quantitative A-scan only B-scan (with or without superimposed non-quantitative A- scan) anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy Unilateral procedure Reimbursed at 100% for each eye Subject to MPPR reduction Indications and Guidelines Ophthalmic ultrasound, AKA ocular echography, uses high frequency sound waves to examine the eye structure and diagnose disorders A-scan is 1-D, used for simple cataract B-scan ultrasound, AKA bright scan, cross sectional 2-D view of the eye structure For dense cataract or precluded visualization of the posterior segment of eye A-scan covered under Medicare when performed prior to cataract surgery Usually only 1 A or B scan in 12 month period Codes subject to 26/TC split LCD s available at NGS and CGS 22

23 Ophthalmic A Scan and Optical Coherence Biometry CPT Codes Ophthalmic biometry by ultrasound echography, A-scan with intraocular lens power calculation Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation PC is unilateral Reimbursed at 100% for each eye TC is bilateral No increase in reimbursement Subject to MPPR reduction Indications and Guidelines Cataract extraction with lens implantation 2 methods for Intraocular Lens (IOL) determination Measures length of eye Covered under Medicare when performed prior to cataract surgery Medicare allows more than one scan if surgery is postponed 23

24 Visual Field Testing CPT Codes Visual field examination, unilateral or bilateral, with interpretation and report; Limited examination (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) Very limited screening test only Intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) Used for suspected neurological damage Extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2) Suspected slow progressive dimming of peripheral vision (glaucoma) Guidelines CPT descriptions indicate extent and types of visual field Number of isopters documented needed to support level Written report Bilateral No increase in reimbursement Can use modifier 52 for one eye Subject to MPPR Continued... 24

25 Visual Field Testing Indications Disorder of the eyelids potentially affecting the visual field Prosthesis difficulties in an anophthalmic socket Advanced glaucoma or suspected glaucoma Disorder of the optic nerve, the neurological visual pathway, or retina Recent intracranial hemorrhage, mass or increased pressure Recent occlusion and/or stenosis of cerebral arteries, transient cerebral ischemia or giant cell arteritis History of a cerebral aneurysm, pituitary tumor, occipital tumor or other condition potentially affecting the visual fields A visual field defect demonstrated by gross visual field testing Significant recent eye injury Unexplained visual loss Part of an initial workup for buphthalmos, congenital anomalies of the posterior segment or congenital ptosis Disorder of the orbit, potentially affecting the visual field Pale or swollen optic nerve New functional limitations which may be due to visual field loss (i.e., reports by family that patient is running into things) Use of a medication (e.g., Plaquenil) which has a high risk of potentially affecting the visual system Initial evaluation for macular degeneration Review LCD s at WPS, NGS and CGS 25

26 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) CPT Codes Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Guidelines Retinal thickness analysis Codes indicate area of eye examined (anterior, optic nerve, retina) AKA Heidelberg Retina Tomograph (HRT) study and bundled per NCCI edits Bilateral procedure, no increase in reimbursement Subject to MMPR Continued... 26

27 SCODI Indications Glaucoma Valuable diagnostic tool in the diagnosis and treatment of glaucoma Enable discernment of changes of the nerve fiber even in advanced cases of glaucoma. 2 exams per eye per year maximum for most carriers Retinal disorders Including macular abnormalities 2 exams per eye per year for disease management Up to one exam per month for active treatment Limitations Considered experimental for certain disorders: Narrow angle, suspected narrow angle, mixed narrow & open angle glaucoma Determination of IOL Iris tumor Calculation of lens power for cataract patients who have undergone prior refractive surgery Review LCD s available at First Coast, Novitas, CGS, NGS, WPS 27

28 Surgical Procedures Cataract Surgery Blepharoplasty/Blepharoptosis 28

29 Cataract Surgery CPT Codes Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) Excise posterior lens capsule due to cloudy and thickened lens after cataract surgery Removal of lens material; aspiration technique, 1 or more stages Floating lens material after artificial lens implantation Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (e.g., phacoemulsification), with aspiration Mechanical or ultrasound to break down lens material and remove Removal of lens material; pars plana approach, with or without vitrectomy Incision through pars plana (middle of eye between retina and iris); access vitreous Removal of lens material; intracapsular Removal of lens and surrounding capsule; freezes lens on cryoprobe Removal of lens material; intracapsular, for dislocated lens May be result of trauma or Marfan s syndrome Removal of lens material; extracapsular (other than 66840, 66850, 66852) Leaves elastic capsule in place for implantation of IOL Continued... 29

30 Cataract Surgery CPT Codes (continued) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage Complex code is intended to differentiate the extra work performed during the intraoperative or postoperative periods in a subset of cataract operations A miotic pupil which will not dilate sufficiently to allow adequate visualization of the lens in the posterior chamber of the eye, and requires additional techniques Pediatric cataract surgery The use of capsular dye for the assisted visualization of the anterior capsule in performing capsulorhexis (anterior capsule made in a smooth circular pattern vs can opener technique) Intracapsularcataract extraction with insertion of intraocular lens prosthesis (1 stage procedure) Removes lens and capsule; inserts lens prosthesis Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification) Elastic capsule is retained; IOL inserted 30

31 Blepharoplasty/Blepharoptosis Blepharoplasty CPT Codes Blepharoplasty, lower eyelid; with extensive herniated fat pad Blepharoplasty, upper eyelid; with excessive skin weighting down lid Blepharoptosis CPT Codes Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia) frontalis muscle technique with autologous fascial sling (includes obtaining fascia) (tarso) levator resection or advancement, internal approach (tarso) levator resection or advancement, external approach superior rectus technique with fascial sling (includes obtaining fascia) conjunctivo-tarso-muller's muscle-levator resection (e.g., Fasanella-Servat type) Brow Ptosis CPT Codes Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Continued... 31

32 Blepharoplasty/Blepharoptosis Indications Indications When performed as functional/reconstructive procedures Blepharoplasty procedures to correct Visual impairment due to dermatochalasis or blepharochalasis Symptomatic redundant skin which is resting on upper lashes Chronic, symptomatic dermatitis of pretarsal skin Prosthesis difficulties in an anophthalmic socket Blepharoptosis repair to correct Visual impairment due to droop or displacement of the upper lid Brow ptosis repair to correct Visual impairment due to droop or displacement of the brow Brow malposition which would prevent adequate correction of dermatochalasis, blepharochalasis or blepharoptosis Documentation Guidelines* Visual Fields Taped and Untaped Upper visual field improvement at least 20% taped (8 degrees) Showing Visual Field obstruction of at least 30 degrees Documentation of Medical Necessity Patient s complaint that defines the functional deficit Difficulty reading or driving due to upper eyelid drooping Looking through the eyelashes or seeing the upper eyelid skin Chronic blepharitis Photographs Front and side views *Guidelines vary by carrier 32

33 ICD-10-CM Updates 2017 Chapter 7: Diseases of the Eye and Adnexa 12 Deleted Codes 100 New Codes 8 Revised Codes 6th Characters for new and revised codes 1 = Right eye 2 = Left eye 3 = Bilateral 9 = Unspecified eye 33

34 ICD-10-CM Updates Retinal Vein Occlusions Deleted Codes H34.81x: Central retinal vein occlusion Right, Left, Bilateral or Unspecified H34.83x: Tributary (branch) retinal vein occlusion Right, Left, Bilateral or Unspecified New Codes H34.81xx: Central retinal vein occlusion, OR H34.83xx: Tributary (branch) retinal vein occlusion 7 th character indicates With macular edema (7 th = 0) With retinal neovascularization (7 th = 1) Stable (7 th = 2) 6 th character still indicates Right, Left, Bilateral or Unspecified 34

35 ICD-10-CM Updates Nonexudative Age-Related Macular Degeneration Deleted Codes H35.31: Nonexudative agerelated macular degeneration New Codes H35.31xx: Nonexudative agerelated macular degeneration 7th character indicates Stage unspecified (7th = 0) Early dry stage (7th = 1) Intermediate dry stage (7th = 2) Advanced atrophic without subfoveal involvement (7th = 3) Advanced atrophic with subfoveal involvement (7th = 4) 6th character still indicates Right, Left, Bilateral or Unspecified 35

36 ICD-10-CM Updates Exudative Age-Related Macular Degeneration Deleted Codes H35.32: Exudative agerelated macular degeneration Lacks stage and involvement Lacks laterality New Codes H35.32xx: Exudative agerelated macular degeneration 7th character indicates Stage unspecified (7th = 0) With active choroidal neovascularization(7th = 1) With inactive choroidal neovascularization (7th = 2) With inactive scar (7th = 3) 6th character still indicates Right, Left, Bilateral or Unspecified 36

37 ICD-10-CM Updates Primary Open-Angle Glaucoma Deleted Codes H40.11Xx: Primary openangle glaucoma Identified stage but not laterality Used Placeholder X in 6 th character position New Codes H40.11xx: Primary openangle glaucoma 7th character indicates Stage unspecified (7th = 0) Mild stage (7 th = 1) Moderate stage (7 th = 2) Indeterminate stage (7th = 3) 6th character now indicates Right, Left, Bilateral or Unspecified 37

38 ICD-10-CM Updates New Codes H53.04x: Amblyopia suspect H59.33x: Postprocedural hematoma of X eye and adnexa following an ophthalmic procedure H59.34x: Postprocedural hematoma of X eye and adnexa following other procedure H59.35x: Postprocedural seroma of X eye and adnexa following an ophthalmic procedure H59.36x: Postprocedural seroma of X eye and adnexa following other procedure 6th character identifies laterality 38

39 ICD-10-CM Updates Revised Codes Revised From H59.31x: Postprocedural hemorrhage and hematoma of X eye and adnexa following an ophthalmic procedure Revised To Postprocedural hemorrhage and hematoma of X eye and adnexa following an ophthalmic procedure 39

40 ICD-10-CM Updates Diabetes with Ophthalmic Manifestations Code range E08 through E13 add laterality Example: Deleted E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema Added E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral E Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye 40

41 ICD-10-CM Updates Diabetes with Ophthalmic Manifestations Additional codes identify increased ophthalmic conditions With proliferative and nonproliferative diabetic retinopathy Stable, mild, moderate, severe, or not indicated, with or without macular edema Diabetic macular edema resolved following treatment Traction retinal detachment involving or not involving the macula Combined traction retinal detachment and rhegmatogenous retinal detachment New codes identify laterality and bilaterality Example E Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral 41

42 Questions? Contact Information 42

43 Resources Medicare Coverage Database &ContrVer=1&CntrctrSelected=379*1&s=34%7c48%7c53%7c58&bc=AggAAAQAAAAAA A%3d%3d& Medicare Physician Fee Schedule Payment/PhysicianFeeSched/index.html 43