Getting Paid for Technology

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1 Getting Paid for Technology Harvey Richman, OD Rebecca Wartman, OD Optometry s Meeting June 2018 Disclaimers for Presentation 1.All information was current at time it was prepared 2.Drawn from national policies, with links included in the presentation for your use 3.Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations 4.Prepared and presented carefully to ensure the information is accurate, current and relevant 5.No conflicts of interest exist for presenters- financial or otherwise. However, Rebecca and Harvey write for Optometric Journals Disclaimers for Presentation 6. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services 7. AOA, AOA-TPC, Optometry s Meeting, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein 8. The content of the COPE Accredited CE activity was prepared with assistance from Kara Webb (AOA Staff) and Doug Morrow OD 1

2 Disclaimers for Presentation Cornea and Anterior Segment Eye Review Maps 2

3 Ocular higher order wavefront maps Ocular higher order wavefront maps 3D view Settings 3

4 Corneal wavefront allows direct comparison of corneal and ocular wavefronts Compare corneal with total WF Corneal wavefront allows direct comparison of corneal and ocular wavefronts Tangential and 4

Axial Curvature Measurments Topography color

zone options 92025 Topography Computerized

with interpretation and report Detection of

5 Axial Curvature Measurments Topography color scales Elevation maps Various overlay and fit zone options Topography Computerized corneal topography, unilateral or bilateral with interpretation and report Detection of subtle corneal surface irregularity and astigmatism 16 5

$Indications & Limitations of Coverage: Post penetrating keratoplasty Post kerato refractive complications Post op irregular astigmatism Corneal dystrophy, bullous keratopathy Complications of$

6 Indications & Limitations of Coverage: Post penetrating keratoplasty Post kerato refractive complications Post op irregular astigmatism Corneal dystrophy, bullous keratopathy Complications of transplanted cornea, Keratoconus Reasons For Denial: Non covered for refractive procedures Often billable privately for contact lens evaluations or included in examination fee Corneal Hysteresis Uses air impulse stimulation Unilateral or bilateral I Interpretation and report 6

Low Corneal Hysteresis Optic nerve damage Visual field loss Functional progression of GLC Larger magnitude of IOP reduction Dynamic finding that may increase after medications are implemented No

7 Low Corneal Hysteresis Optic nerve damage Visual field loss Functional progression of GLC Larger magnitude of IOP reduction Dynamic finding that may increase after medications are implemented No utilization guidelines No published LCD Some Medical Policy list as E/I/U Anterior segment imaging interpretation and report Specular microscopy and endothelial cell analysis Bilateral Service Justified Slit lamp evidence of endothelial dystrophy (guttata) Slit lamp evidence of corneal edema Undergoing secondary intraocular lens implant Previous ocular surgery now requires cataract surgery Fitting with extended wear contact after ocular surgery Limitations If only visual problem is cataract not eligible considered part of presurgical examination. Not covered in preoperative evaluation of refractive keratoplasty 7

Corneal Confocal Microscopy Examines unmyelinated corneal nerve fibers @ high magnification, using laser scanning CCM to image corneal sub basal nerve plexus Can predict insipient

demonstrate utility for CCM in other neuropathies Corneal Confocal Microscopy Blepharoplasty Guidelines Visual field examinations used determine medical necessity for blepharoplasty Often

8 Corneal Confocal Microscopy Examines unmyelinated corneal nerve high magnification, using laser scanning CCM to image corneal sub basal nerve plexus Can predict insipient peripheral neuropathy in Type 1 DM (63% Sensitive; 74% Specific) Reduced Corneal NFL length & Corneal sensitivity = increased severity diabetic peripheral neuropathy Previous studies demonstrate utility for CCM in other neuropathies Corneal Confocal Microscopy Blepharoplasty Guidelines Visual field examinations used determine medical necessity for blepharoplasty Often performed twice, taped lids and untapped lids Repeated service should be submitted with CPT modifier 76 on a separate detail line but often denied External Photos now often used Review carrier LCD 8

New Blepharoplasty Guidelines CGS: Complaint Physical findings Visual fields Noridan: Complaint Physical finding Photos WPS: Complaint Physical findings Visual

eliminated Visual Fields requirement Blepharoplasty Photos Anterior Segment Photography 92285 External ocular photography with interpretation and report for

9 New Blepharoplasty Guidelines CGS: Complaint Physical findings Visual fields Noridan: Complaint Physical finding Photos WPS: Complaint Physical findings Visual fields Photos Cahaba: Complaint Physical findings Visual fields Photos Palmetto: Complaint Physical findings Photos 5 Carriers with LCD for Blepharoplasty 2 have eliminated Visual Fields requirement Blepharoplasty Photos Anterior Segment Photography External ocular photography with interpretation and report for documentation of medical progress (eg, close up photography, slit lamp photography, gonio photography, stereo photography) Medicare Fees National Non Facility Fee $

10 External Ocular Photography Bilateral Code Check carrier for limitations or restrictions of coverage External ocular photography is covered when a special camera is used to obtain magnified photographs of lesions (e.g., the cornea, iris or lids) for purpose of following the patient's condition Medical quality images may be of digital, Polaroid Macro 3 SLR or equivalent Photographs for purpose of documenting for medicolegal purposes or preauthorization (e.g., gross trauma, amount of ptosis or redundant lid tissue) are not separately reimbursed not medically necessary SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction Iris tumor Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL No using 52 modifier or LT or RT modifier if only CPT codes not covered with SCODI: 76512,

11 Pupilometry Pupilometry Pupilometry 11

12 Pupilometry CPT 0341T Pupilometry Quantitative pupillometry with interpretation and report, unilateral or bilateral RVU=0 Local Carrier Priced MGD Dysfunction 12

13 MGD Imaging Ocular Surface Interferomoter CPT III CODES 0330T Tear film Imaging unilateral or bilateral report 0207T Clear eyelid gland w/ heat/intermittent pressure 13

Lens Autofluorescence FDA Market Clearance 2013 Lens Autofluorescence Using Lens Fluorescence Biomicroscope calibrated with standards

= 94% (Hemoglobin A1C: Sens.= 44%, Spec.= 79%) (Fasting Plasma Gluc.: Sens.=50%, Spec.

14 Lens Autofluorescence FDA Market Clearance 2013 Lens Autofluorescence Using Lens Fluorescence Biomicroscope calibrated with standards traceable to National Institute of Standards and Technology (NIST): Type 2 DM Detection (via AGEs on lens) Sensitivity = 67%, Specificity = 94% (Hemoglobin A1C: Sens.= 44%, Spec.= 79%) (Fasting Plasma Gluc.: Sens.=50%, Spec.= 95%) Takes 6 secs, non invasive, doesn t require fasting Lens Autofluorescence Integral to General Ophthalmologic or E&M Now No LCD/ Medical Policy could be considered but not recommended 14

15 92072 Fitting of a contact lens for management of keratoconus, initial fitting. For subsequent fittings, use either the 9921X or 9201X codes. Report materials in addition to this code, using either or the appropriate HCPCS Level II material code. Question: At what point after the initial fitting of a keratoconus lens is a new lens (not a replacement) billable with code due to the fact that the lens no longer fits the patient s need? Answer: Description of work for initial fittings includes the results of diagnostic tests done prior to contact lens fitting to assess the corneal ectasia, which and are used in concert with slit lamp examination to assess corneal shape and determine initial contact lens parameters (eg, diameter, base curve, and secondary curves). Lens designs can include corneal, scleral, hybrid, or piggyback systems. Keratometry, lid anatomy, tear film, and refraction are also performed and/or rechecked. If the lens need to be changed because it no longer fits the patient s needs, the fitting of new lens is considered an initial fitting and should include all of the services noted above. CPT Assistant September

Glaucoma 92020 Gonioscopy Used to diagnose injury or disease in anterior chamber of eye, performed under local anesthetic due

Visual Field Examinations 92081 Limited, unilateral or bilateral, with interpretation and report; examination 92082

16 Glaucoma Gonioscopy Used to diagnose injury or disease in anterior chamber of eye, performed under local anesthetic due to necessity of placing specialized lens directly on the eye to obtain a clear image Bilateral Procedure Code LCD Utilization Visual Field Examinations Limited, unilateral or bilateral, with interpretation and report; examination Intermediate, unilateral or bilateral, with interpretation and report Extended, unilateral or bilateral, with interpretation and report 16

Glaucoma Management 5 0 A Baseline visual fields B Glaucoma Hemifield Test

GPA Alert F VFI plot: Visual Field Index Display of Trend (3 5yrs) under

Rate of Progression / Significance Guided Progression Analysis B A F H G C

17 Glaucoma Management 5 0 A Baseline visual fields B Glaucoma Hemifield Test C Current visual field D GPA / Deviation from Baseline (Event Analysis) E GPA Alert F VFI plot: Visual Field Index Display of Trend (3 5yrs) under current conditions (Trend Analysis) G VFI Bar: Remaining useful vision H Rate of Progression / Significance Guided Progression Analysis B A F H G C D E Guided Progression Analysis Change of baseline intuitive & quick operation 17

18 Serial Visual Field Overview Visual Field Overview Serial Visual Field Overview Indications & Limitations of Coverage Necessary to establish diagnosis Monitor course for treatment Determine change in therapeutic plan 18

Indications & Limitations of Coverage 92081 92082 medically necessary to diagnose and

MILD visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees)

19 Indications & Limitations of Coverage medically necessary to diagnose and follow retinal disorders diagnosis or follow up of glaucoma or neurologic disease MILD visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees) MODERATE visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees) 19

SEVERE visual field abnormality (inner circle = 10

All services are considered bilateral 50 modifier not

if doing repeat procedure Scanning Laser Tests Confocal

20 SEVERE visual field abnormality (inner circle = 10 degrees, outer circle = 20 degrees) Coding Guidelines VF All services are considered bilateral 50 modifier not appropriate 52 modifier if only doing one eye 76 modifier if doing repeat procedure Scanning Laser Tests Confocal laser scanning ophthalmoscopy (topography) Optical Coherence tomography 20

21 Versatile Multi Modality Imaging Glaucoma Versatile Multi Modality Imaging Coding guidelines Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral or bilateral No using either a 52 LT or RT modifier if reduced CPT codes not covered with SCODI: 92225, 92226, modifier usage GA modifier usage with ABN 21

22 92133 Glaucoma Indications Scanning Computerized Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve Technological improvements have rendered SCODI as valuable diagnostic tool in diagnosis and treatment of glaucoma. These improvements enable discernment of changes of nerve fiber even in advanced cases of glaucoma. Expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma. Glaucoma Severity/Staging Level Scanning Laser Frequency Current frequency limitations for Scanning Laser for most regions: Mild or Suspect Glaucoma Moderate Glaucoma Advanced or Severe Glaucoma 1 Time per year 2 Times per year NO Scanning laser but up to 4 Visual Fields / year Utilization Guidelines GLC Although CMS guidelines state Only two exams/eye/year are allowed for patient who has or is suspected of having glaucoma Most LCD state once per year to follow pre glaucoma patients or those with mild stage One or two tests per year for patients with moderate staging, followed with SLT or visual fields if both SLT and visual fields are used, only one of each tests Advanced stage, field testing preferred by Medicare guidance 22

Ganglion Cell Analysis Isolates Ganglion Cell Layer Measures thickness for sum of GCL and IPL layers using data from Macular cube scans.

specific anatomy, use GCL and IPL thickness Excludes RNFL Thickness Map Show thickness measurements of the GCL + IPL in the 6mm by 6mm cube and Deviation contains Maps an

GCL annulus + IPL of the thickness Thickness to Map tableinto normative Shows 6 regions: average data.

23 Ganglion Cell Analysis Isolates Ganglion Cell Layer Measures thickness for sum of GCL and IPL layers using data from Macular cube scans. RNFL distribution in the macula depends on individual anatomy, while the GCL+IPL appears regular and elliptical for most normal individuals Propriety algorithms are adapted for specific anatomy, use GCL and IPL thickness Excludes RNFL Thickness Map Show thickness measurements of the GCL + IPL in the 6mm by 6mm cube and Deviation contains Maps an elliptical Show Sector a maps annulus - centered comparison divide the about elliptical of the fovea. GCL annulus + IPL of the thickness Thickness to Map tableinto normative Shows 6 regions: average data. 3 equally and minimum sized sectors thickness in the within superior the region elliptical and annulus. Horizontal and 3 equally sized Vertical B-scans. sectors in the inferior region. Values are compared to normative data. Ganglion Cell Analysis Key Elements Diagnostic CPT's Pachymetry: CPT Bilateral. Billable for Corneal Problems and Glaucoma. Requires Interpretation and Report. 23

report by a physician or other qualified health care professional 0464T 0464T Visual Evoked Potential, testing for

24 Visual Field Technology 0378T Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 0464T 0464T Visual Evoked Potential, testing for glaucoma, with interpretation and report (For visual evoked potential screening for visual acuity, use 0333T) Macular Diseases 24

25 All relevant information on 1 screen First visit Prior visit Todays visit Screen Layout 1 glance to see change Visualization of change Navigate multiple visits all at once Synchronized navigation 25

Versatile Multi Modality Imaging RPE Detachment

26 HD Line raster in MultiMode Navigator Completes the combined information between OCT data and fundus images Versatile Multi Modality Imaging RPE Detachment Versatile Multi Modality Imaging Proliferative Diabetic Retinopathy 26

27 Versatile Multi Modality Imaging Versatile Multi Modality Imaging Diagnostic Insight 27

Greater Diagnostic Insight Review Integrated Images and Registered OCT Scans 92134 Scanning Computerized Ophthalmic Dagnostic Imaging, posterior segment, with

These technologies are valuable tools for evaluation and treatment of patients with retinal disease, especially macular abnormalities.

92134 Scanning Computerize Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Utilization Guidelines AMD/DR

28 Greater Diagnostic Insight Review Integrated Images and Registered OCT Scans Scanning Computerized Ophthalmic Dagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Retinal disorders are most common causes of severe and permanent vision loss. These technologies are valuable tools for evaluation and treatment of patients with retinal disease, especially macular abnormalities. These imaging techniques are useful tools to measure effectiveness of therapy, and in determining need for ongoing therapy, or safety of cessation of therapy Scanning Computerize Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Utilization Guidelines AMD/DR Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease One exam/eye/month is allowed for the patient who is undergoing active treatment for macular degeneration or diabetic retinopathy Glaucoma? 28

Fundus Autofluorescence (FAF) Potential info health & function

molecules susceptible to damage/x linking, & shed their

molecules stored in liposomes, forming lipofuscin (LF) Disease

accumulation Hypo fluorescence = RPE cells die/are absent

29 Fundus Autofluorescence (FAF) Potential info health & function of entire retina Photoreceptors contain light sensing molecules susceptible to damage/x linking, & shed their damaged outer segments RPE phagocytize the segments & molecules stored in liposomes, forming lipofuscin (LF) Disease states & oxidative damage = LF Hyper fluorescence = excess LF accumulation Hypo fluorescence = RPE cells die/are absent LASER Speckle Flowgraphy Noninvasive way to assess ocular blood flow CRVO study completed 29

92250:Fundus Photography Fundus photography with interpretation and report Bilateral Code 90 Photography Document

30 Angiography software OCTA Non invasive, dyeless Hi res, 3 D visualization of retinal vasculature Images motion of scattering particles such as RBCs using sequential OCT x sectional scans :Fundus Photography Fundus photography with interpretation and report Bilateral Code 90 Photography Document abnormalities Check carrier s medical policy for limitations or restrictions of coverage Obtain filing requirements from carrier for bilateral or multiple procedures 91 30

31 92250 Utilization Guidelines Fundus photography. Generally, it is not medically necessary to repeat fundus photography more often than every 2 years for follow up of stable glaucoma. Repeat photographs for retinopathy are rarely necessary. Wide Field Retinal Screening S9886 Not Medically Necessary Service Patient is aware not medically necessary Screenings are not covered in most cases 31

32 Macular Pigment Densitometers No Current LCD No Current Defined Code Studies Inconclusive Image from Marco MPOD Assesment 92081? Heterochromic Flicker Photometry 92081? 32

Preferential Hyperacuity Perimeter Discontinued 92082?

LCDs Changing Most TPP experimental except for plaquenil Not for EOMs New code

? 95930 Visual Evoked Potential UPDATE 2018 Visual Evoked Potential (VEP)

33 Preferential Hyperacuity Perimeter Discontinued 92082? ERG Electroretinography with interpretation and report Bilateral Code LCDs Changing Most TPP experimental except for plaquenil Not for EOMs New code coming?? Visual Evoked Potential UPDATE 2018 Visual Evoked Potential (VEP) checkerboard or flash testing, central nervous system, except glaucoma, with interpretation and report Bilateral Code General Supervision Special Training? Utilization Guidelines HERE 33

0333T 0469T Retinal polarization scan, ocular screening with on site automated results, bilateral Retinal Birefringence scanners (RBS) hand held instruments measure the changes

Medicare payments (Resource Based Relative Value System) Identify pairs of services not billed together (same physician for same patient on same day) Component element edits o

34 0333T 0469T Retinal polarization scan, ocular screening with on site automated results, bilateral Retinal Birefringence scanners (RBS) hand held instruments measure the changes in the polarization of light detect eye misalignment or strabismus No LCD Medical Policy E/I/U National Correct Coding Initiative (NCCI) Developed with RBRVS 2003 Insures proper Medicare payments (Resource Based Relative Value System) Identify pairs of services not billed together (same physician for same patient on same day) Component element edits o and Medically Unlikely Edits (MUE) policy manual o or and but MAY use 59 modifier o and may NOT be used together even with 59 modifier 34

NCCI Edits MUE together, column 1 code is paid MUE MAY be allow together o 0 not allowed o 1 allowed o 9 non applicable o If clinical circumstances justify appending a modifier to column 2 code of

35 NCCI Edits MUE together, column 1 code is paid MUE MAY be allow together o 0 not allowed o 1 allowed o 9 non applicable o If clinical circumstances justify appending a modifier to column 2 code of code pair, payment for both codes may be allowed MUST READ AND UNDERSTAND WHAT CAN BE DONE TOGETHER AND WHEN Cannot use a modifier just to get paid NCCI Edits Relevant to Optometry Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (e.g., CPT codes 92132, 92133, 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code (CPT code was deleted January 1, 2011.) CPT code (fitting of contact lens for treatment of ocular surface disease) should not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea. Modifier 59 Definition Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances Modifier 59 should not be used to bypass a Procedure to Procedure (PTP) edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI (National Correct Coding Initiative) associated modifier that is used. 35

36 Modifier 59 History Most widely used modifier according to the Centers for Medicare & Medicaid Services (CMS) Associated with considerable abuse High levels of manual audit Triggers reviews and appeals Results in civil fraud and abuse cases Fundus Photography & SCODI Continued confusion on billing photography and SCODI on same date of service They are mutually exclusive as defined by current NCCI Mutually exclusive is defined as procedures that cannot reasonably be performed at the same anatomic site or same encounter. Fundus Photography & SCODI There has been no specific document defining when you can use and with This means there is no official CMS guidance on using mutually exclusive codes on the same date of service. 36

37 Modifier 59 New CMS Guidance Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site. (See example 5 Modifier 59) Modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ Clinical Decision We know that using modifier 59 has potential to trigger audits NCCI policy statement seems to give provider some wiggle room to use 59 modifier Providers need to use caution if choose to use modifier 59 Coding Experts recommend that scans be performed on different visits to avoid potential for audits. Modifier 59 Changes Since January 5, 2015 new X code modifiers Intended to more clearly define Distinct Procedural Service Rules for use have not been written 37

38 New Modifiers Further Defining Modifier 59 X modifiers meant to define subsets of Modifier 59 X modifiers provide more precise coding options CMS acknowledges that increased education is needed CMS only modifiers CPT manual has not been changed New Modifiers X(EPSU) Modifiers XE Separate Encounter: Service that is distinct because it occurred during a separate encounter New Modifiers X(EPSU) Modifiers XS Separate Structure: Service that is distinct because it was performed on a separate organ/structure 38

39 New Modifiers X(EPSU) Modifiers XP Separate Practitioner: Service that is distinct because it was performed by a different practitioner New Modifiers X(EPSU) Modifiers XU Unusual Non Overlapping Service: Use of a service that is distinct because it does not overlap usual components of the main service. New Modifiers X(EPSU) Modifiers CMS continues to recognize Modifier 59 Instructions state that 59 should not be used when a more descriptive modifier is available Providers should not use modifier 59 and a new X modifier together for the same code 39

40 YOU SURVIVED Questions? Thank You! 40

Dr. Harvey Richman, OD, FAAO, FCOVD Diplomate American Board of Optometry Executive Committee AOA Third Party Center Founder Ask the AOA Coding

Dr. Harvey Richman, OD, FAAO, FCOVD Diplomate American Board of Optometry Executive Committee AOA Third Party Center Founder Ask the AOA Coding Experts 92000 Codes Special Ophthalmological Services Describe