Optometric Billing-Billing for an Exam on the Same Day as a Surgical Procedure Such as Dry Eyes or Epilation

It has always been my opinion that in order to bill for an exam on the same day as providing a surgical procedure, such as dry eyes, that one would have to have notated evidence that the examination portion of the encounter was not in fact related to the surgical procedure.  It turns out that after some further research into my coding guidelines this is not just my opinion, it is fact. Let's take a look at how this should be handled.

IE: The patient came into the office for a routine exam or yearly check-up and at that time it was decided that the patient qualified for punctal plugs or epilation. (The plugs would be rare in this instance as it is now necessary to try every other treatment possible BEFORE proceeding with inserting the plugs). 

So, in the example above, the physician would note that "the patient was in for a yearly check up and during the course of exam the patient described to the physician that though the drops he has been using for his dry eye syndrome help somewhat, they are still relatively ineffective at times and he would like to know if there is anything else he could try. At this time the physician offers the option of punctal plugs as they have been shown to be a very effective, though minimally invasive, method of treating the patient's condition. "

If  the condition above, or any other combination of supporting evidence, is present you now have a justifiable basis for billing the insurance company for 1) A comprehensive examination 2) Punctal Plugs. The example above would be billed in a manner similar to the following:

1) 92014-25 (25 modifier means the exam is a separate service from the actual plugs themselves)

2) 68761 (one plug in either eye) or 68761-50 (1 plug in both eyes) or 68761-51 (2 plugs in the same eye) or better still 68761 E1 (E1 meaning it was the upper left lacrimal duct E3 would be upper right and E2E4 are lower left and right respectively). SEE BELOW 

If the condition in the above example is not met, by no means should you bill an insurance company for an exam AND a surgical procedure.At this point, it is understood that the procedure for plugs or epilation etc. includes any examination that need be done. Furthermore,  UNLESS a patient comes into the office for an exam during the 10 DAYS subsequent to the punctal plug procedure for something UNRELATED to the previous procedure you cannot bill the patient's insurance for any further items. In this case, you would bill the proper examination procedure code, followed with a -24 modifier (unrelated E/M procedure during post-op period) SEE BELOW

CLICK HERE TO VIEW THE OFFICIAL MEDICARE COVERAGE INFORMATION FOR BILLING PUNCTAL PLUGS.

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Optometric Billing-Billing For Punctal Plugs

This was burried in our internal notes and is article written by  John Rumpakis, O.D., M.B.A., Clinical Coding Editor. You can find the original text for this article by clicking here.

"Signs and symptoms of dry eye syndrome are often discovered during a comprehensive exam. When further testing is indicated, this may be best done as a follow-up evaluation. This evaluation for dry eye syndrome most likely involves several examination techniques and ancillary tests. These tests, which do not have separate procedure codes, include:

• Patient history (dry eye surveys, symptoms, circumstances, etc.) 

• Tear film break-up time (TFBUT) • Schirmer testing (I&II)  

• Cotton thread or phenol red thread testing 

• Sodium fluorescein, lissamine green and/or rose bengal staining  

• Tear prism evaluation  

• Evaluation of lid wiper epitheliopathy

• Biomicroscopy and examination of ocular surface and lid margins

These tests help you formulate the diagnosis. The appropriate diagnosis code is usually dry eye syndrome (375.15) or keratitis sicca (370.33). Sjögren’s syndrome/keratoconjunctivitis sicca (710.2) is also a possibility, although you should be familiar with your carrier’s requirements prior to initiating any therapy.

In general, before contemplating either surgical or prescriptive treatment, you should have a well documented record of palliative therapy with an artificial tear protocol. The failure of the artificial tear treatment is what provides the medical necessity to proceed to more invasive treatment.

Once you’ve made the diagnosis of dry eye and formalized a treatment plan, several subsequent visits are typically necessary to evaluate the treatment plan. Both the diagnostic and treatment visits are billed using the appropriate office visit codes only. Keep in mind that if you perform the diagnostic examination on the same date as the comprehensive exam, it is not billable as a separate/distinct visit in addition to the comprehensive examination. Follow-up visits to assess the effectiveness of treatment, to alter or to add to the treatment plan are billed using 99212, 99213 or 92012. 

If you decide the patient requires punctal plugs, the billing is the same for temporary diagnostic plugs and permanent plugs. The supply of the punctal plugs is typically included in the insertion code. The insertion procedure is billed per plug in one of two ways. Here is the first method: 

• One plug: 68761  

• Two plugs, different eyes: 68761-50 (billed at 200% of one plug) 

• Two plugs, same eye: 68761-51 (billed at 200% of one plug) 

• Three plugs: 68761-50 (billed at 200% of one plug) and 68761-51 (billed at 100% of one plug) 

 • Four plugs: 68761-50 (billed at 200% of one plug) and 68761-50-51 (billed at 200% of one plug) 

The “multiple surgery rule” applies, so the payment is typically 100% for first plug, 50% for the second plug, and 25% for each of the third and fourth plug. The -50 modifier indicates a bilateral procedure on the same eye and the -51 modifier indicates multiple procedures on the same eye. See Appendix A in your CPT book for further details. 

The second method for billing punctal occlusion is adding the E modifiers to the surgical code to designate which puncta are being occluded. Bill for each plug on a separate line using the appropriate E modifier: 

• E1: upper left  

• E2: lower left  

• E3: upper right 

 • E4: lower right 

The global period for punctal occlusion is 10 days. So, if a patient returns within that period for a follow-up visit related to the punctal occlusion, then that visit is included in the insertion fee. However, if a patient returns for an unrelated problem, then that office visit must be billed using a -24 modifier (unrelated evaluation and management during a postoperative period) in order for you to be compensated for that encounter. "

We would like to thank Dr. Rumpakis for his continued contributions to Medical Coding. His work has proved to be very valuable to our cause as well as many OD's around the country.

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Optometric Billing- Does Medicare Cover Routine Eye Exams?

I get this question all the time, sometimes doctors even demand that I "respect their authoritah" (Eric Cartman pun intended) and trust them when they tell me that Medicare Pays for Routine Eye Exams.

Simply put, MEDICARE DOES NOT PAY FOR ROUTINE EYE EXAMS, EXCEPT FOR PATIENTS WITH DIABETES. 

"Medicare Part B (Medical Insurance) covers a yearly eye exam for diabetic retinopathy by an eye doctor who is legally allowed to do the test in your state." link

That being said, if you try to bill Medicare using a V72.0, 367.21, 367.0, 367.4,367.1 DX Code as your primary DX code, expect not to get paid; and if Medicare doesn't cover it, chances are the patient's secondary may not pick it up either, although this is not a definite rule as it varies by payer and patient plan.

By the way, for those docs and staff out there that think you are being paid for routine work because the EOB says you were paid for a "92004 and 92015"....YOU ARE MISTAKEN AND YOU MUST LEARN TO RESPECT MY "AUTHORITAH" !

OPTOMETRIC BILLING-INCREASE REVENUE, BY 50 PERCENT?!?!

I recently came across a website that specializes in medical billing for opthalmologists. The owners of the site, and likely the business, claim right on the home page that you can  "INCREASE YOUR REVENUE BY 50% WHEN YOU OUTSOURCE YOUR BILLING!" .

I CALL BULLSHIT!

I know, I know. It is unprofessional of me to curse on a professional blog site but can you honestly blame me? If you stop and think about it for one second, doesn't that make you feel a little bit stupid as a doctor to see someone advertise to you that they can increase your business by 50% if you just outsource your billing!?!? Maybe stupid isn't even the right word. Maybe foolish is better. Maybe you can think of a better word to describe the feeling that that statement evokes and post it in the comment section below. The bottom line, however, is that no matter how you slice it that is just false advertisement, PERIOD.

First of all some simple math. If your business bills $50k per year to medical insurance it's absolute fodder to believe that outsourcing that job will all of a sudden bring you $50k more per year in insurance business, how does that add up? Where is the logic there? Also, let's just say that the claim this advertiser is making means that you will simply just collect 50% more by outsourcing your billing and your current collection rate is 50%, you will now add $12.5k more money to your bottom line bringing your overall collection rate to only 75% which is the industry average, you can do better than that, why settle for less?

No matter what angle you look at it from, insurance just doesn't work that way. Quite simply, insurance is nothing more than a corporate lottery. These companies are in the business of making money and will do whatever they can to keep their reimbursement rates as low as possible meaning you, the provider, and the patient loose big time. Do you really think that outsourcing is going to improve your odds of DRASTICALLY improving your revenue?

Don't get me wrong. Outsourcing is a great thing and will DEFINITELY improve your revenue and your cash flow if you choose the right partner to outsource too. However, there is no way that I or anyone else can guarantee you that you will improve revenue by 50% if you just outsource your billing. The answer to improving your revenue begins and ends with you, the practice owner. You want to increase your current revenue? You should  outsource your billing to a company like opticXpress who focuses on increasing your collection percentage AND works with your patients. This frees up your office staff giving them the time and flexibility to focus on what matters most, your patients. Second, you should increase your business which is single handedly the only tried and true method to increase revenue. Last, TRAIN YOUR STAFF! A well trained staff who understands patient satisfaction and insurance eligibility procedure not only keeps your customers (patients) happy but it cuts down on billing errors and keeps you "in the black".

So, the next time someone tells you that you can increase revenue just from outsourcing, pipe up and call bullshit.

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Optometric Billing-Free Optometric Billing?

That's right! opticXpress is working on a way to provide optometrists with a FREE* method to perform optometric billing that centers around their office management software. More info is coming soon, but check their software page for more info about how the ground breaking opticXpress software might be a fit for your practice.

You can also CLICK HERE for software info.

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