Optometry Billing-Medicare, VSP and Others Increase Audits

* "Medicare, Blue Cross, VSP and ALL  other payers have increased their audits. They know that most practice's documentation is NOT COMPLIANT! Typical Penalties are between $100,000 and $200,000 ! Most practices fail these audits. "





*This came from our friends at Eyecor. opticXpress is a re-seller of Eyecor coding software you can contact us by clicking here to get more info about this ground breaking software. For help with a pending insurance Audit, a Past Insurance Audit or to protect yourself from a possible future audit please contact Eyecor's Nteon Practice consultants by clicking here. 

Nteon Practice Consultants are experienced in what auditors are looking for. They have conducted many audits throughout the country and these audits include a review of compliant documentation, reports, HIPPA and lost reimbursements just to name a few.

Optometric Billing at Saratoga Springs!

This weekend, March 22-24, opticXpress will be hosting an exhibit at the Saratoga Springs Coding Conference in Saratoga Springs, NY. We encourage you to come visit us and see what we have to offer and what we are all about.

We will also be joined at our table by the president of Liquid EHR which is our choice for clients that need high quality EHR software. Also, we will be highlighting our free billing software and EyeCor, coding software for OD's.

We hope to see you there!

For more info, please call us at 866-688-3335 x1.

Click Here to Let opticXpress Become Your Optometric Billing Service Today.

Optometric Billing-92072-Fitting of Contact Lens for Keratoconus-V2531

Admittedly this post should have been made in January of 2012 however, we are putting it up now because we have noticed large search traffic coming to our site specifically for the term "Keratoconus, Contact Lens"

That being Said, we bill for this procedure at Stowe Eyecare using a blend of guidance from EyeCOR  and an article written by Gregory W. DeNaeyer, O.D., F.A.A.O, for optometricmanagement.com .When billed properly, most medical plans will cover not only the fitting but the actual materials/supplies as well. NOTE: IT IS EXTREMELY IMPORTANT THAT YOU CO-ORDINATE YOUR CARE WITH THE PATIENT'S INSURANCE AND VERIFY COVERAGE BEFORE YOU GO AHEAD WITH THE PROCEDURE AS IT CAN UNDOUBTEDLY COST THE PATIENT ALOT OF MONEY OUT-OF-POCKET. NOW THAT THE AFFORDABLE CARE ACT IS IN HIGHER EFFECT, MANY PATIENTS THAT YOU PERFORM THIS PROCEDURE ON WILL HAVE HIGH-DEDUCTIBLE PLANS SO, EVEN THOUGH IT IS COVERED, THEY WILL STILL HAVE TO PAY FOR IT.

The proper code for the actual initial fit of a Keratoconus Scleral Lens is 92072 and is either UNILATERAL or BILATERAL with potential modifiers being RT, LT, or 50 (I do not like using the 50 modifier for ANY bilateral procedure but that is admittedly a personal bias on my part).

EyeCOR Note: "This procedure code is new as of January 2012.
This procedure does NOT include the supply of lens. Use the appropriate V-code to separately report the materials.
To report subsequent visits, use 992xx or 920xx exam code." 

You can then bill the insurance company for lenses themselves on the same day using V2531. Again, the materials are either Unilateral or Bilateral depending on the actual fit itself. (Another personal bias and GOOD CODING HABBIT: Always list exam procedures on a claim BEFORE materials. It's less messy looking, more precise and it actually does give your claims a chance at getting paid properly the first time, without human intervention at the insurance company.)

Claim Example:

(Be sure to take a look at an EyeCOR subscription by CLICKING HERE. We are not in partnership with them, nor do they pay for advertising through us. We are giving them FREE advertising on our site because we love their product so much, and we believe you will also.)

For help with optometric billing in your practice, contact opticXpress today!

Optometric Billing-New Glaucoma Codes - THEY ARE REQUIRED!

***Pulled the following article from ODWire. As always, you can contact opticXpress for help with your optometric billing.

Robert E Rebello
EyeCOR

As of Oct 1, 2011 new Glaucoma codes went into effect. The majority of Optometrists and Ophthalmologists are unaware or do not have a complete understanding of these new codes. At three Optometry meetings in October, most doctors and their staffs had not heard about these new codes.

We at EyeCOR have put together this article explaining the new codes and their proper usage.

The new Glaucoma codes are “Stage” codes which specify the level or Stage of Glaucoma severity.

The new Stage codes are:

• 365.70 – Unspecified Stage Glaucoma
• 365.71 – Mild or Early Stage Glaucoma
• 365.72 – Moderate Stage Glaucoma
• 365.73 – Severe Stage Glaucoma
• 365.74 – Indeterminate Stage Glaucoma

Use the appropriate Stage code for the patient’s worst eye.

These Stage codes are secondary and coded immediately after the actual Glaucoma Diagnosis code. Stage codes cannot be used without the primary Glaucoma Diagnosis.

Note: These new codes are in effect for Medicare. Other payers are required to use the new codes beginning January 1, 2012. At this time other payers may not recognize them.

The following Glaucoma codes require one of the Stage codes:

365.10, 365.11 365.12 365.13, 365.20, 365.23, 365.31, 365.52, 365.62, 365.63 and 365.65

Do not use the Stage codes for Glaucoma Suspect or other glaucoma diagnoses not included above.

Coding Tip: We recommend not using either 365.70 or 365.74 as they are “Unspecified” or “Indeterminate.” Frequently payers deny reimbursement for Unspecified diagnoses. Instead code the specific Stage of Glaucoma.

Coding Tip: Make sure all procedures that point to the Glaucoma diagnosis using the Diagnosis Pointer (Form Locator: 24 E) point to the actual Glaucoma diagnosis not the Stage diagnosis (See Coding Example 1).

Coding Example 1 - Mild - Primary Open Angle Glaucoma:



Coding Example 2 - Glaucoma Suspect (No Stage code):



Other Ramifications when using the New Stage Codes

Most regions restrict certain procedures based on Severity levels. One example is the frequency limitations for Scanning Laser (OCT, GDx and HRT). Previously, for Advanced Glaucoma damage, you could perform up to 4 Scanning Laser procedures per year. Most regions currently do not allow any Scanning Laser for Advanced or Severe Glaucoma damage. Instead payers may allow up to 4 Visual Fields per year in order to track damage.

Therefore, when you code 365.73 – Severe Stage Glaucoma you will likely be denied reimbursement for Scanning laser. In addition, if you now code “Severe” Glaucoma and previously performed Scanning Laser on this patient, the payer may look back at previous claims and demand you return reimbursement for those procedures.

The current frequency limitations for Scanning Laser for most regions are:

Glaucoma Severity Level	Scanning Laser Frequency
Mild or Suspect Glaucoma	1 Time per year
Moderate Glaucoma	2 Times per year
Advanced or Severe Glaucoma	NO Scanning laser. Up to 4 Visual Fields

Avoid the temptation to stay away from the “Severe” glaucoma code. If you are audited and found to be using incorrect Stage codes, you could be in for more trouble.

Glaucoma Suspect Code Changes

In addition to the new Stage codes for Glaucoma, CMS has also changed the descriptions for two Glaucoma Suspect codes (365.01-.02) and adding two new codes (365.05 -.06). The new descriptions and codes are:

• 365.01 – Open Angle Glaucoma with Borderline Findings – Low Risk
• 365.02 – Anatomical Narrow Angle – Primary Angle Closure Suspect
• 365.05 – Open Angle Glaucoma with Borderline Findings – High Risk
• 365.06 – Primary Angle Closure Without Glaucoma Damage

The differentiation is Low and High Risk and Closure without Glaucoma Damage.

Make sure when coding Glaucoma Suspect, you use the codes with the description matching the patient’s diagnosis.

Glaucoma Severity Definitions

CMS defines Glaucoma severity as follows. Make sure you use the correct Severity Level based on the worst eye:

Glaucoma Suspect or Mild Damage (one or more of the following)

- Intraocular pressure >22 mmHg as measured by applanation.

- Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio Greater than 0.4.

- Focal optic disc notch.

- Optic disc hemorrhage or history of optic disc hemorrhage.

- Nasal step or small paracentral or arcuate scotoma.

- Mild constriction of visual field isopters.

Moderate Damage (one or more of the following)

- Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio Greater than 0.5 & Less than 0.9

- Definite focal notch with thinning of the neural rim.

- Definite glaucoma visual field defect (arcuate/paracentral scotoma, nasal step, pencil wedge, constriction of isopters

Advanced or Severe Damage (one or more of the following)

- Severe generalized constriction of isopters (i.e., Goldmann I4e <10 degrees of fixation).

- Absolute visual field defects within 10 degrees of fixation.

- Severe generalized reduction of retinal sensitivity

- Loss of central visual acuity, with temporal island remaining

- Diffuse enlargement of optic nerve cup, with cup to disc ratio Greater than 0.8

- Wipeout of all or a portion of the neural retinal rim.

Summary
With the addition of the new Glaucoma Stage codes and new Glaucoma Suspect codes, proper coding can be complex. You need to ensure your practice is coding Glaucoma correctly. Otherwise, you could find your practice receiving unnecessary denials resulting in lost reimbursement.

For additional information contact EyeCOR:
Toll Free: 888-866-5367
Web: www.EyeCOR.com
Email: info@EyeCOR.com Copyright 2011 - Nteon Software LLC
EyeCOR is a register trademark of Nteon Software LLC