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Reimbursement Payers

Last year was a challenge formost practices withMedicare—for some morethan others—and there aremore challenges ahead in

2011. Several changes were made inthe 2011 edition of the CPT manual,some in the ICD-9 coding manual,and several items in the Office ofInspector General (OIG) 2011 WorkPlan that affect ophthalmology.

CPT Code Changes The CPT has added two new codes tothe Cornea section to allow the oph-thalmologist to describe repair of the

ocular surface using amniotic mem-brane tissue for burns or injuries notrequiring extensive reconstruction.Codes 65778 and 65779 describerepairing damaged tissue of thecornea or conjunctiva using a singlelayer of amniotic tissue with or with-out suturing. These new codes are todistinguish ocular surface repair fromthe more complex procedure of ocu-lar surface reconstruction with amni-otic tissue, code 65780, which usesmultiple layers.

The new procedure codes areexpected to be performed in anoffice setting; the code 65780 is

expected to be performed in a hospi-tal or ASC setting. The cost for theamniotic tissue is included in thenon-facility (office) relative valueunits. The surgeon’s fee is reducedconsiderably when he performseither of the procedures in a facility(ASC or hospital).

Glaucoma specialists alsoreceived two new surgical codes. TheCPT converted the temporary codesfor the transluminal dilation of theaqueous outflow canal, codes 0176Tand 0177T, to permanent Category Icodes 66174 and 66175. These codesdescribe canaloplasty or visco-canalostomy with or without stent.

CPT revised the description ofthe laser iridotomy (66761) to reflectthe shorter global fee period estab-lished by CMS for 2011. The proce-dure is now paid per session in a 10-day global period instead of one ormore sessions in a 90-day globalperiod.

Category III code 0191T,Insertion of anterior segment aque-ous drainage device, withoutextraocular reservoir; internalapproach, into the trabecular mesh-work, was revised by CPT and anoth-er temporary code was added, code0253T. These two codes describe dif-ferent approaches to facilitate theflow of aqueous fluid. Code 0191Tdescribes placing the device in thetrabecular meshwork and code0253T describes placing it into thesuprachoroidal space. Currently, sev-eral carriers/contractors deem theservice to be investigational.

The scanning computerized oph-thalmic imaging (SCODI) procedurecodes (92135 and 0187T) have beensplit into three different codes toincorporate the anterior segment,optic nerve, and retina (92132,

2011 Medicare Update Heather B. Freeland

The practice needs to be diligent inensuring that the correct CPT procedurecode is used to describe the services andthat the documentation is present in thechart to support the billed charge.

AE Spring 2011 63

92133, and 92134). A major changefrom the deleted codes and the threenew codes is that they now say “uni-lateral or bilateral.” In Medicare lan-guage, that means bilateral andincludes both eyes. The replacedcodes were unilateral or per eye.Under the Correct Coding Initiative,the two posterior segment codes arebundled and not billable even withdifferent diagnoses. The -59 modifierwould not apply since both testsinvolve the same segment of the eye.

Another new set of codes wasestablished by CPT to allow thereporting of remote imaging for dia-betics who might have diabeticretinopathy, codes 92227 and 92228.Code 92227 is used to report imag-ing services for the asymptomaticdiabetic patient who is at risk fordeveloping retinopathy. The screen-ing test can be performed under aphysician’s general supervision butdoes not require a physician’s pres-ence. The physician, however, mustprovide an analysis and report. Code92228 is used when the diabeticpatient has already been diagnosedwith active retinopathy and requiresphysician review, interpretation, andreport. These procedure codes can-not be reported together on thesame day or with any office visitcodes. Codes for fundus photos,SCODI-optic disc, or SCODI-retinaare considered duplicative and can-not be billed with either of the newcodes.

CPT Modifier ChangesThere are some minor revisions tothe modifiers listed in CPT but nonew modifiers. CPT added thephrase “or other qualified healthcareprofessional” to modifiers -76, -77and -78.

Included in the definitionchanges is a subtle change in themeaning of the -50 modifier. The -50modifier tells Medicare or privateinsurers the procedure was per-formed on both sides. Until now, the

modifier appeared to only apply tosurgeries. With this change, CPTintends for it to apply to any bilater-al procedure performed during thesame session, including diagnosticservices. As a reminder, this modifieris only used for unilateral servicesthat are performed bilaterally.

ICD-9-CM ChangesThere was only one major change tothe diagnosis coding that affectsophthalmology. A new section andcategory of diagnoses was added todescribe retained foreign objects andthe type. The code range is V90-V90.9. The codes will be used withthe primary condition code such asretained magnetic foreign body,code 360.5, which will need codeV90.10 or V90.11 to identify themetal foreign object.

OIG Work PlanEach year, the Office of InspectorGeneral (OIG) publishes a Work Planthat provides descriptions of activi-ties the OIG plans to initiate or con-tinue. The OIG is responsible forprotecting Medicare integrity andMedicare beneficiaries by detectingand preventing fraud and abuse. Forophthalmologists, optometrists, andoptical shops, the OIG has severalareas of interest; some are Works inProgress, others are “new starts.”

Works in progress include thefollowing:

1. Place of Service Errors: The OIGis reviewing surgeries performed inthe ASC but billed as performed inthe physician’s office.

2. ASC Payment System: The OIGis reviewing the appropriateness ofthe methodology of setting the ASCrates.

3. Coding of Evaluation &Management (E&M) Services: The OIGis looking into the coding patternsof E&M services and how they varyby physician characteristics.

4. Payments for E&M Services:

The OIG continues to review med-ical records for proper supportingdocumentation for the level of serv-ice billed. They will look into elec-tronic medical records to identifydocumentation practices that couldlead to improper payments byMedicare.

5. E&M Service During GlobalSurgical Periods: The OIG will deter-mine if the number of services pro-vided in surgical global periods haschanged since 1992. If the serviceshave decreased, it could eventuallymean a decrease in the Medicarepayment for that service.

6. Medicare Payments for ClaimsDeemed Not Reasonable and Necessary:The OIG will review the contractors’payment for services billed witheither the -GA or -GZ modifiers tomake sure the services would trulybe denied as not reasonable andnecessary. They are also looking atthe medical policies Medicare carri-ers/contractors have for these modi-fiers to see if they need to be updat-ed.

7. Medicare Payments for DurableMedical Equipment (DME) Claims withModifiers: The OIG will review thoseclaims in which proper medical doc-umentation was indicated (-KXmodifier). Audits by the DME MACshave indicated there was little or nodocumentation in the chart to sup-port the modifier.

8. Acquisition Costs and Paymentsfor Lucentis and Avastin Used inTreating Wet Age-Related MacularDegeneration: The OIG will examinehow physicians’ acquisition costscompare to Medicare’s payment forthese two drugs. They will also lookat the additional costs of com-pounding Avastin. Based on theirfindings, they may recommend thatMedicare lower the Avastin pay-ments again.

9. Usage Patterns and Paymentsfor Avastin and Lucentis in TreatingWet Age-Related Macular Degeneration:

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The OIG will review data to identifyusage patterns and payments forthese two drugs and determine if sig-nificant savings can be realized ifeither drug is used more by an oph-thalmologist.

New start items include the fol-lowing:

1. Excessive Payments forDiagnostic Tests: The OIG will begincomparing the costs for testingordered by both the primary care

physician and a specialist for thesame condition.

2. Medicare Providers’ Compliancewith Assignment Rules: The OIG willlook at physicians with regard to anyassignment rule violations andwhether patients have been billedmore than the coinsurance anddeductible as required by theirassignment agreement. It will deter-mine if Medicare patients are awareof any possible billing violations and

if they are aware of Medicare cover-age guidelines.

3. Medicare Billings with Modifier–GY: The OIG will examine the useof the -GY modifier. Providers arenot required to give beneficiariesadvance notice of charges for servic-es that are excluded from Medicareby statute, and patients may beunknowingly acquiring large medicalbills for which they are responsible.The OIG wants to make sure theservices are truly excluded and non-covered by Medicare.

4. Payment for Services Ordered orReferred by Excluded Providers: TheOIG will review CMS’ oversight pro-cedures for identifying and prevent-ing payment for services ordered orreferred by excluded physicians.

5. Error-Prone Providers: TheOIG will look at the top error-pronephysicians who consistently submitclaims found to be in error. The OIGwill conduct additional medicalreviews on the top error-proneproviders and request refunds of anyoverpayments made by Medicare.

Bottom LinePractices need to be diligent inensuring that the correct CPT proce-dure code is used to describe theservices and that the documentationis present in the chart to support thebilled charge. Not only will the prac-tice receive correct reimbursement, itwill survive a post-payment auditand be able to keep that hard-earnedpayment from Medicare. AE

continued from page 63

Focusing on the BUSINESS of Ophthalmology

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Heather B. Freeland (800-720-9667; results@roseandassociates.com) is thedirector of coding and compli-ance at Rose & Associates,Duncanville, Texas. Rose &Associates is a nationally rec-ognized healthcare consultingfirm specializing in Medicarereimbursement and compli-ance for the specialty of oph-thalmology.

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