NextGen Healthcare RCM Eye Care

Transcription

1 NextGen Healthcare RCM Eye Care

2 Before we get started there are a few housekeeping items This Webinar is being recorded For an uninterrupted presentation, lines will be muted for the duration of the webinar We will address questions at the end of the presentation Throughout the presentation feel free to submit questions via the Q&A tool at the bottom right hand corner of your webex screen.

3 Today s Speaker Maria Shinn Bouck Director Ophthalmology RCM Financial Services

4 Agenda Vision vs. Medical General Eye Care Beginner Biometry Anterior Chamber Intermediate Laterality Modifiers & Dx coding All Intermediate Dx coding Unspecified Eyes & Staging All - Intermediate Taxonomy Code Changes Retina/Oculofacial/Glaucoma/Uveitis Intermediate Eye Code vs. E/M Code All Intermediate Best Practice in Audit Response Anterior Chamber / Glaucoma / Retina Advanced Post Op Visit Reporting All Intermediate Drug Billing Basics Retina General Intermediate Consolidated Billing All Advanced Corneal Tissue in the ASC ASC Advanced 2017 OIG Work Plan & Ophtho All Beginner MIPS Clinical Improvement Activities All - Advanced

5 Vision vs. Medical Insurance Vision Benefits Covers Routine eye care Exam Materials (glasses or Contact Lenses) Assessment of refractive state Near sightedness Far sightedness Astigmatism Presbyopia Max Benefits 1 exam every months Materials every months Medical Benefits Covers Eye-related MEDICAL problems Exam Diagnostic Testing Therapeutic Intervention Eye disease Systemic disease affecting the eye

6 All three things have to Line Up

7 Order of Operations to Check Claim Validity

8 Billing VISION Insurance Vision Insurance has a limited number of CPT & HCPCS codes that may be billed to them The only CPT codes that can be billed to Vision Insurance are: Eye Exams: Refractions: Contact Lens Fittings: , Non Medical Contact Lenses: The only HCPCS codes that can be billed to Vision Insurance are: Eye Exams with Refraction: S0620 S0621 Frames: V2020 V2025 Lenses & Lens treatments: (see attached HCPCS spreadsheet) Non Medical Contact Lenses (see attached HCPCS spreadsheet) Any procedure code billed outside of this scope is an invalid claim

9 Routine Vision Dx NEVER MEDICAL H52.00 Hypermetropia, unspecified eye H52.01 Hypermetropia, right eye H52.02 Hypermetropia, left eye H52.03 Hypermetropia, bilateral H52.10 Myopia, unspecified eye H52.11 Myopia, right eye H52.12 Myopia, left eye H52.13 Myopia, bilateral H Unspecified astigmatism, right eye H Unspecified astigmatism, left eye H Unspecified astigmatism, bilateral H Unspecified astigmatism, unspecified eye H Irregular astigmatism, right eye H Irregular astigmatism, left eye H Irregular astigmatism, bilateral H Irregular astigmatism, unspecified eye H Regular astigmatism, right eye H Regular astigmatism, left eye H Regular astigmatism, bilateral H Regular astigmatism, unspecified eye H52.31 Anisometropia H52.32 Aniseikonia H52.4 Presbyopia H52.6 Other disorders of refraction H52.7 Unspecified disorder of refraction

10 Eye Codes Can be Vision OR Medical

11 Refraction CPT code CPT code is ALWAYS ROUTINE VISION regardless of the diagnosis If the patient does not have routine vision or their benefits are exhausted (usually 1x every 12 months) then the service is a patient responsibility Vision insurances often bundle into the eye exam

12 Vision vs. Medical in the ASC There is no circumstance where billing a Vision insurance for ASC Facility based claims is correct. Billing vision ins in the ASC is always wrong. Every Code, Every encounter = Medical or Self Pay

13 Vision vs. Medical in Ophthalmic Testing There is no circumstance where billing a Vision insurance for diagnostic testing is correct. Billing vision ins for diagnostic testing is always wrong. Every Code, Every encounter = Medical or Self Pay

14 Vision vs. Medical in Therapeutic Intervention There is no circumstance where billing a Vision insurance for therapeutic intervention, office procedure or surgical procedure is correct. Billing vision ins for any therapeutic intervention or surgery is always wrong. Every Code, Every encounter = Medical or Self Pay

15 Vision vs. Medical for Eye Exams Vision Ins limited to Eye Exam & Refraction codes: S0620 S0621 Medical Ins may bill Eye Exams or E/M (992xx) codes Presenting Problem drives Vision vs. Medical Eye Exams

16 Vision vs. Medical in the Optical Dispensary Most Eyewear & Contact Lenses are paid by patients or by VISION INSURANCE Exception: Once in a lifetime post cataract glasses for Medicare Part B / Part C patients Dispensary materials are HCPCS codes beginning with V NOT ALL V-Codes are Materials

17 Vision vs. Medical in Contact Lenses Contact lenses are billed to vision insurance or patients Exception: Bill to DME Contact lenses used as bandages Contact lenses used to corneal disease such as keratoconus Contact lenses for patients born without natural lenses (Aphakia)

18 Valid Combinations of CPT PROC + Dx + Ins w/ A/R Actions CPT Code(s) *= most common Diagnosis (Dx) Code(s) Insurance Correct / Incorrect Action (Anesthesia Labs) (Eye Codes + Refraction) Medical (NOT H52.xxx) Medical Ins Correct None Vision (H52.xxx) Vision Ins Correct None (Eye Codes) Medical (NOT H52.xxx) Medical Ins Correct None (Eye Testing) Medical (NOT H52.xxx) Medical Ins Correct None (CTL Fitting Refractive) Vision (H52.xxx) Vision Ins Correct None (CTL Fitting Disease) (CTL Fitting Refractive) (Glasses Refractive) (Glasses Prosthesis) Medical (NOT H52.xxx) Medical Ins Correct None Vision (H52.xxx) Vision Ins Correct None Vision (H52.xxx) Vision Ins Correct None Medical (Not H52.xxx) Medical Correct None (Glasses Refractive) Vision (H52.xxx) Vision Ins Correct None (Glasses Prosthesis) Medical (Not H52.xxx) Medical Correct None (Eye Testing / Medicine) Medical (Not H52.xxx) Medical Correct None

19 Valid Combinations of HCPCS PROC + Dx + Ins w/ A/R Actions HCPCS Code(s) *= most common V2600 V2615 (DME for Low Vision) Diagnosis (Dx) Code(s) Insurance Correct / Incorrect Medical (NOT H52.xxx) Medical DME Ins Correct None V2623 V2629 (Prosthetics) Medical (NOT H52.xxx) Medical DME Ins Correct None V2630 V2632 (Implants) Medical (NOT H52.xxx) Medical Ins Correct None Action V2787 V2788 (Premium IOL) V2785, V2790 (tissue / transplant) Vision (H52.xxx) Self Pay Correct May bill to Medical Insurance for Denial Medical (NOT H52.xxx) Medical Ins Correct None J0001 J9999 (Drugs) Medical (NOT H52.xxx) Medical Ins Correct None C0001 C9999 (Drugs / Implants) Medical (NOT H52.xxx) Medical Ins Correct None V2020 V2025 (Frames) Vision (H52.xxx or Z96.1) Vision Ins OR Medical DME Ins (LTE) V2100 V2499 (lenses) Vision (H52.xxx or Z96.1) Vision Ins OR Medical DME Ins (LTE) V2500 V2531 (Contact Lenses) V2700 V2784, V2797, V2799 (Lens treatments) Vision (H52.xxx or Z96.1) Vision (H52.xxx or Z96.1) Vision Ins OR Medical DME Ins (LTE) Vision Ins OR Medical DME Ins (LTE) Correct Correct Correct Correct Self Pay for Non Cov or Upsells. Once in a lifetime for DME Self Pay for Non Cov or Upsells. Once in a lifetime for DME Self Pay for Non Cov or Upsells. Once in a lifetime for DME Self Pay for Non Cov or Upsells. Once in a lifetime for DME

20 Invalid Combinations of CPT PROC + Dx + Ins w/ A/R Actions CPT Code(s) *= most common Diagnosis (Dx) Code(s) Insurance Correct / Incorrect Action (Anesthesia Labs)* Vision (H52.xxx) Medical Ins Incorrect Change Dx (Anesthesia Labs)* Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins (Eye Codes + Refraction)* (Eye Codes + Refraction)* Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins Vision (H52.xxx) Medical ONLY Ins Incorrect Change Dx, bill refraction to patient (Eye Codes) * Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins (Refraction) Medical (NOT H52.xxx) Vision Ins Incorrect Bill patient or Bill ONLY w/ Eye Codes (Eye Testing)* Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins (CTL Fitting Refractive) Medical (NOT H52.xxx) Medical Ins Incorrect Change CPT Code (CTL Fitting Refractive) Vision (H52.xxx) Medical Ins Incorrect Change Ins (CTL Fitting Refractive) Medical (NOT H52.xxx) Vision Ins Incorrect Change Dx

21 Invalid Combinations of CPT PROC + Dx + Ins w/ A/R Actions CPT Code(s) *= most common Diagnosis (Dx) Code(s) Insurance Correct / Incorrect Action (CTL Fitting Disease)* Medical (NOT H52.xxx) Vision Incorrect Change Ins (CTL Fitting Disease) Vision (H52.xxx) Vision Incorrect Change CPT (CTL Fitting Disease) Vision (H52.xxx) Medical Incorrect Change Dx (CTL Fitting Refractive) Vision (H52.xxx) Medical Incorrect Change Ins (CTL Fitting Refractive) (CTL Fitting Refractive) Medical (NOT H52.xxx) Medical Incorrect Change CPT Medical (NOT H52.xxx) Vision Incorrect Change Dx (Glasses Refractive) Vision (H52.xxx) Medical Incorrect Change Ins (Glasses Prosthesis) Medical (Not H52.xxx) Vision Incorrect Change Ins (Eye Testing / Medicine)* (Eye Testing / Medicine)* Vision (H52.xxx) Medical Incorrect Change Dx Medical (Not H52.xxx) Vision Incorrect Change Ins

22 Invalid Combinations of HCPCS PROC + Dx + Ins w/ A/R Actions HCPCS Code(s) *= most common V2600 V2615 (DME for Low Vision) V2600 V2615 (DME for Low Vision) Diagnosis (Dx) Code(s) Insurance Correct / Incorrect Action Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins Vision (H52.xxx) Medical DME Ins Incorrect Change Dx V2623 V2629 (Prosthetics) Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins V2623 V2629 (Prosthetics) Vision (H52.xxx) Medical DME Ins Incorrect Change Dx V2630 V2632 (Implants) Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins V2630 V2632 (Implants) Vision (H52.xxx) Medical Ins Incorrect Change Dx V2785, V2790 (tissue / transplant) Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins V2785, V2790 (tissue / transplant) Vision (H52.xxx) Medical Ins Incorrect Change Dx J0001 J9999 (Drugs)* Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins J0001 J9999 (Drugs) Vision (H52.xxx) Medical Ins Incorrect Change Dx

23 Invalid Combinations of HCPCS PROC + Dx + Ins w/ A/R Actions HCPCS Code(s) *= most common C0001 C9999 (Drugs / Implants) C0001 C9999 (Drugs / Implants) Diagnosis (Dx) Code(s) *=rare exceptions for congenital or corneal Insurance Correct / Incorrect Action Medical (NOT H52.xxx) Vision Ins Incorrect Change Ins Vision (H52.xxx) Medical DME Ins Incorrect Change Dx V2020 V2025 (Frames) Medical (NOT H52.xxx or Z96.1) Vision Ins Incorrect Change Dx V2020 V2025 (Frames) Vision (H52.xxx or Z96.1) Medical Ins Incorrect Change Ins V2100 V2499 (lenses) Medical (NOT H52.xxx or Z96.1) Vision Ins Incorrect Change Dx V2100 V2499 (lenses) Vision (H52.xxx or Z96.1) Medical Ins Incorrect Change Ins V2500 V2531 (Contact Lenses) Medical (NOT H52.xxx or Z96.1)* Vision Ins Incorrect Change Dx V2500 V2531 (Contact Lenses) Vision (H52.xxx) Medical Ins Incorrect Change Ins V2700 V2784, V2797, V2799 (Lens treatments) Medical (NOT H52.xxx or Z96.1)) Vision Ins Incorrect Change Dx V2700 V2784, V2797, V2799 (Lens treatments Vision (H52.xxx or Z96.1) Medical Ins Incorrect Change Ins

24 Biometry w/ IOL Calc & Both codes are inherently bilateral for the technical component & inherently unilateral for the professional component 2017 Medicare Fee schedule change (peeled away global, TC, 26) and assigned indicators correctly. Some MACs only imported one indicator (2 inherently bilateral) Fix by 4/3/2017, retro d to 1/1/2017

25 Biometry Billing Bilateral IOL Master Same day: (no lateral modifiers) Bilateral IOL Master Different days: Day 1: TC (+/- laterality modifiers MAC or payor specific) Day 2: (ibid) Unilateral IOL Master: TC bilateral reimbursement per surgical case s/b ~ $ bilateral reimbursement per surgical case s/b ~$115

26 Laterality match your mods w/ your Dx Cataract, retinopathy and many other eye diseases. (exception is glaucoma for now) RT, Dx ends in 1 LT, Dx ends in 2 Create query, edit for same

27 Unspecified Eyes & Staging A word about unspecified eyes Bad for principle diagnosis Good for subspecialists not handling the particular disease burden but want to report it Ie: Retina doc treating maculopathy, but wants to report severity & complexity of illness & isn t the one staging the glaucoma. Dx: (a) H Toxic maculopathy, right eye, (b) H40.10X0 Unspecified open-angle glaucoma, stage unspecified Unspec Stage you re not the doc treating the problem Indeterminate Stage- (H40.10X4) you ARE the doc treating the problem but VF / optic nerve damage is still in work up phase

28 Taxonomy Codes for Sub Specialty - DIY Ophthalmology - 207W00000X Glaucoma Specialist - 207WX0009X Ophthalmic Plastic and Reconstructive Surgery - 207WX0200X Retina Specialist - 207WX0107X Uveitis and Ocular Inflammatory Disease - 207WX0108X MIPS & Cost Factor Credentialing credentialing credentialing

29 Taxonomy Definitions Glaucoma Specialist: An ophthalmologist who specializes in the treatment of glaucoma and other disorders related to increased intraocular pressure and optic nerve damage. This specialty involves the medical and surgical treatment of these conditions. Ophthalmic Plastic and Reconstructive Surgery: A physician who specializes in oculofacial plastic and reconstructive surgery. This subspecialty combines orbital and periocular surgery with facial plastic surgery, and includes aesthetic and reconstructive surgery of the face, orbit, eyelid, and lacrimal system. Practitioners evaluate, diagnose and treat conditions involving the eyelids, brows, midface, orbits, lacrimal systems and surrounding and supporting structures of the face and neck. Retina Specialist: An ophthalmologist who specializes in the diagnosis and treatment of vitreoretinal diseases. Uveitis and Ocular Inflammatory Disease: An ophthalmologist who specializes in the treatment of intraocular inflammation, scleritis, keratitis and infectious disorders affecting the eye and inflammatory disorders of the adnexa and/or orbit.

30 Eye Code vs. E/M Code CMS Comprehensive Error Rate Testing (CERT) 3.5% nationally for Ophthalmology - $290M nationwide Comparative Billing Report (CBR) FAQ: Q: Why should we use CPT code for a NP as CPT code is a higher paying code & obviously a NP takes longer? A: Providers should use the procedure code which most accurately describes the service rendered, regardless of the allowed amount

31 Eye Code vs. E/M Code Background & Nature of Issue: Eye care providers often have a choice to bill Eye code or EM codes when treating medical eye problems. The AAO recommends assessing favorable payment and when EMR supports either, to bill for the most advantageous code set. Below is an excerpt from an AAO article concerning Eye vs. E/M. Ophthalmology is fortunate to have two choices when it comes to the code selection of an office exam E&M codes (99XXX) and Eye codes (92XXX). So how do you determine which of the two is the best selection? Gather data ahead of time and your practice can quickly choose the most appropriate code after you ve decided the level of service. The most efficient practices know what each insurance carrier s fee schedule will be for the year. Confirm your top payers, and create a spreadsheet outlining both E&M and Eye codes with the allowable amounts of each payer. This way you can compare the two and take advantage of your options.

32 Eye Code vs. E/M Code Procedures for analysis: Select a sufficient enough period. Ie: examine 2016 Eye & E/M encounters. Examine ONLY settled charges with no bad debt. Exclude the principle dx of H52.xx (refractive error range) from sample & extrapolations. All modeled / examined encounters s/b medical in nature, non refractive, no routine services. Calculate the average payment per new and established eye code & E/M code per financial class. Display the volume per CPT per financial class and extrapolate maximum possible opportunity to all non-refractive visits Examine medical records to see if x-walked code pair is supported Authorization sometimes limits commercial HPI & ROS typically limit the x-walk from Eye Code to E/M

33 Eye Code vs. E/M Code

34 Best Practice in Audit Response OIG Report September 2015: Questionable Billing for Medicare Ophthalmology Services Cataract Surgery: (Including ASC) Comprehensive Eye Exam w/ findings & treatment plan & order for surgery ** use for 2 nd eye Lifestyle Questionnaire VF8R Biometry w/ IOL Calc Informed Consent Operative Report Valid Signatures the gotcha

35 Best Practice in Audit Response istent / Glaucoma Surgery Comprehensive Eye Exam Glaucoma dx w/ staging Medication treatment w/ notation of adherence IOP Refractory to medication (+/-) Treatment plan w/ order for surgery Operative Report Valid Signature the gotcha

36 Best Practice in Audit Response Lucentis Comprehensive Eye Exam w/ diagnosis & treatment plan prior to injection if subsequent injection or reiteration in HPI, including justification of frequency Medication administration history Ie: Avastin since 2014, now refractory macula Refractory macular findings Order & interpretation for OCT / Imaging Images supporting findings if done Injection procedure note Dosing & administration Valid Signature the gotcha Tell the story

37 Post-Op Visit Reporting - CBD CMS 2015, AMA RBRVS Symposium 2016 roll out of revaluation & elimination of post-op days, tied w/ mis-valued codes initiative. MACRA demanded halt to sudden removal of PO period need data Here s the data part: As of 7/1/2017 providers in groups of > 10 need to report in the post op period of surgeries from the published list (see exhibit) for the following states: FL, KY, LA, NV, NJ, ND, OH, OR, RI Must put the Dx from the SURGERY NOT the Z-code for post op visit in the PRIMARY POSITION. This is how CMS is linking the PO Visits will be especially important in Cat Sx. Ie: Cat Sx RT eye 2/1/2017. PO visit 2/2/2017 Claim on 2/2: ($0.01) Dx (a) H Cortical age-related cataract, right eye, Dx (b) Z Cataract extraction status, right eye, ( c) Z Pseudophakia

38 Drug Billing Basics Determining Units of the HCPCS Code ORDERED dose & definition of HCPCS code Example: TRIESENCE (triamcinolone acetonide injectable suspension) 40 mg/ml SDV of 1 ml HCPCS code J injection, triamcinolone acetonide, preservative free, 1 mg HCPCS units = 40 Summary: 1 Vial, 1 Dose, 1 Mililiter, 40 mg, 40 units No Fractions Avastin differs by state Determining the NDC: format for all payors Leading ZERO in segment NDC: NDC: NDC:

39 Drug Billing Basics Bilateral use of drugs Medicare typically use 1 line item & increase the units Commercials may differ In general don t use directional modifiers unless authorizations drive this Ie: Bilateral Lucentis (0.3mg/OU) Injection unit 1 J2778 NO MOD unit = 6 Billing Waste w/ JW Modifier MLN/MLNMattersArticles/downloads/MM9603.pdf SDV same patient two line items ordered / administered on 1 line item, 2 nd line item remaining dose in SDV w/ JW modifier MDV last patient

40 Consolidated Billing (SNF) Covered Part A Stay check your Medicare MAC for validation 2 Bills: 1 to SNF, 1 to Part B MAC or Part C Carrier SNF: Technical components such as: TC for testing, all pharma MAC: PRO component of testing, eye exams, E/Ms Obtain BUSINESS OFFICE address of SNF (available on Medicare logon) Obtain Accounts Payable (AP) vendor number from business office Send claim on 1500 to business office w/ APN Send letter in 30d to administration Place w/ collections in 60d work w/ attorney at collection agency

41 Corneal Tissue for ASC Contractor priced, (cost +) HCPCS Code: V2785 Processing, preserving and transporting corneal tissue Bill per tissue: MUE of 2 Modifiers: SG for VA & some commercials ONLY (non-medicare) Directional modifiers (RT/LT) REV Code(s) for UB04: 0278 implants **carve outs for implants for commercial carriers? Acquisition of Body Components-Unknown Donor, Service not paid under OPPS but on a reasonable cost basis. Bill w/ invoice will usually get an ADR Effective 1/1/2017 will NOT be paid unless procedure is corneal transplant. Use of corneal wedge for other services is not considered a covered service. Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Claims- Accounting.pdf

42 2017 OIG Work Plan Nothing ophthalmic specific for MACs are handling the CERT findings from 2015 & OIG report from Drug Waste of Single Dose Vials documentation Accurate NDC reporting for cost analysis Medicare payments after date of death ASCs Quality Oversight (audit Medicare certifications for ASCs) Medicare payments for incarcerated patients ** Extent of denied care in Medicare Advantage & CMS Oversight Risk Adjustment payments to Medicare Advantage Plans Get ready for more HCC audits total charts, not payment related

43 MIPS Clinical Improvement Activities See Exhibit II for list of CIAs (15% of overall MIPS score) Need score of 40 (any combination of medium / high, partial credit measure for MIPS) med = 10pts, high = 20pts Engage patients and families to guide improvement in the system of care. IA_BE_14Beneficiary Engagement Medium Engagement of new Medicaid patients and follow-up: Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. IA_AHE_1 Achieving Health Equity High Engagement of patients through implementation of improvements in patient portal. Access to an enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and includes interactive features allowing patients to enter health information and/or enables bidirectional communication about medication changes and adherence. IA_BE_4 Beneficiary Engagement Medium

44 Q&A

45 About NextGen RCM Services NextGen RCM Services provides consulting and outsourcing for physician billing, collections, and claims. We will help you optimize revenue and improve organization-wide efficiency Features a comprehensive reporting package customized for Ophthomology A/R goals set to meet or exceed MGMA/Academy Best Practices Gain the expertise of 900+ billing and practice management experts including: Certified Ophthalmic Coders, Certified Professional Coders Management with a combined 53 years of NextGen experience

46 NextGen RCM Services Our Ophthalmology Clients Achieve Revenue Boosting Results 75% REDUCTION OF A/R OVER 90 DAYS 22% MORE REVENUE TO CLINIC DSO REDUCED 62.5% DENIAL RATE Down to 2% IN 6 MONTHS

47 Revenue Cycle Assessment Offer NextGen Healthcare experts conducts an audit and report key findings about current processes and opportunities for financial optimization Conducted by RCM Services

48 Thank you Contact information for any questions or if you are interested in an assessment: Jill Ryan NextGen Healthcare