No member is an island: FAQs answered by rapid-fire coding consultants

May 13, 2013

By Walt Whitley, O.D., Jason Miller, O.D., and Charles Brownlow, O.D., AOAExcel™ medical & records consultants

This has been quite a busy year addressing numerous coding and billing questions from colleagues across the county. Questions about 2013 Medicare updates, Physician Quality Reporting System (PQRS), and the impact of sequestration are all real concerns for our profession. The good news is the AOA and AOAExcel™ are staying ahead of the game to provide and educate you on how these issues affect your practices and your patients. You should never feel you are on an island if you have questions! The AOA and state affiliates are available to provide numerous resources and timely updates as they become available.

In this month’s “Ask the Codeheads,” we will address a few commonly asked questions we’ve received. Thank you to all who have submitted questions! For those who haven’t, please feel free to contact us at askthecodingexperts@excelod.com. Often, if you are having issues with coding and billing, several of your colleagues may have similar concerns.

Vision vs. medical insurance

Q. We need advice on how to bill medical vs. vision plans. We are having problems getting patients to return for medical testing following a non-medical eye exam and are considering performing these tests the same day. Here are my questions: 1. Is it “okay” to bill medical testing on the same day we are billing a routine eye exam? 2. Is it okay to use a vision plan to cover refraction on a medical visit?

A. The patient’s reason for the visit determines which insurance to bill. If a patient enters with a refractive, non-medical chief complaint/reason for visit, the vision plan should receive the bill for the encounter. If there is a medical complaint/reason for visit, the medical insurance should get the bill for the encounter.

For example, if the patient presents for a vision exam and would like to update their glasses, their vision carrier should get the bill for the encounter (ex. 92014 + 92015 would be billed to the vision plan). If the doctor ordered medical testing during that visit, such as fundus photos (92250) for a choroidal nevus, then medical insurance will be billed for the testing only (92250 would be billed to the medical carrier). Obviously, there are many different scenarios that may occur; however, the reason for the visit determines which insurance to bill for the encounter.

On a medical visit, the vision plan can also be billed for the refraction if it was performed as part of the medical examination. The medical diagnosis would be billed to the medical insurance, which was the main reason for the visit. The refraction with the refractive diagnosis would be billed to the vision plan.

From a practice management perspective, we recommend explaining the “why” to every patient when we “order visits and/or procedures” for them to return to the office. This helps patients understand the differences between medical necessity and vision examinations. Patient education forms explaining the difference between the two types of insurances also help improve patient understanding of why each carrier may be billed.

Updates on CLs for keratoconus

Q. What exactly does 92072 include? Additionally, how to you properly bill for re-fits and yearly examinations if 92072 is only for the initial fitting? How do you use modifier 22 in conjunction with advanced contact lens fittings?

A. The 2013 Current Procedural Terminology (CPT) definition for 92072 is the “fitting of a contact lens for management of keratoconus, initial fitting.” This includes the fitting of the lens, establishing parameters and ordering the lenses. The supply of the lenses should be charged separately using the V codes that best match lens design and material. Some optometrists have had success in getting reimbursed for the procedure but, unfortunately, most insurers will not pay for the fitting and supply of the lenses, even with a medical diagnosis.

It is important to let your patient know he/she will likely be responsible for payment.

As for re-fits, subsequent visits should be reported using either evaluation and management (E&M) codes or general ophthalmological codes that most closely describe the encounter.

The contact lens re-fit would be billed as well using 92310 combined with either 99070 or the V code that most closely matches the type of lens used.

Commonly used V codes for keratoconus include:

  • V2513 Gas permeable (GP) lens, extended wear, per lens
  • V2530 Hybrid contact lens
  • V2531 Gas permeable scleral lens, per lens
  • V2599 Contact lens, other type, per lens

CPT 92310 can be used with different levels of contact lens fitting (standard, complex, advanced, etc.). For the advanced fits (ex. toric GP), you can use the modifier 22 on the 92310 to indicate the higher level of service, complicated fit, etc.

Modifier 22 comes into play when the work required to provide a service is substantially greater than typically required.

It may be identified by adding modifier 22 to the usual procedure code.

Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

This modifier should not be appended to an E&M service.

Fees can be set that are higher than your standard 92310.

Unfortunately, most medical insurance will not pay very often on those fits even though it is necessary for our patients and they need special medical attention.

The bill often falls back on the patient.

Coding Grand Rounds webinar

These are just some of the common questions we receive at askthecodingexperts@excelod.com.

Please feel free to contact us with any other questions.

In our May webinar, Drs. Jason Miller, Charles Brownlow, and Walt Whitley moderate a one-hour “Coding Grand Rounds” webinar and answer questions from the audience. We hope to see you there!

The views expressed are those of the author and do not necessarily reflect the views of the American Optometric Association.

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