Ask the Coding Experts: Frequently Asked Questions

September 24, 2013

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

This month’s column will review some of the common questions we receive from colleagues from across the country. Many of these questions are issues facing numerous offices, so you are not alone. If you have any particular billing and coding questions, email them to us at askthecodingexperts@ excelod.com.

Advance Beneficiary Notice vs. Notice of Exclusions from Medicare Benefits

Q. Can you tell me more about the Advance Beneficiary Notice and how it differentiates from the Notice of Exclusions of Medicare Benefits? Where can I get one and when should I use it?

A. The Advance Beneficiary Notice (ABN) can be used any time you will be providing a service for a patient (fields, photos, imaging, etc.) and you are unsure whether an insurer will cover it. For example, the insurer might say the procedure isn’t paid for when combined with certain diagnosis codes. In this case, have the patient sign the ABN before the test is done, agreeing to pay for the test in the event the insurer does not. The ABN gives providers a chance to explain the uncertainties of the insurance and the fact that no insurance covers everything. Additionally, it is an opportunity to discuss the importance of the testing and that all services not covered or are ruled to be “not reasonable and necessary” by the insurance company need to be paid by the patient. More information is available at www.cms.gov.

The Notice of Exclusions from Medicare Benefits (NEMB) addresses items and services for which Medicare will not pay. Medicare does not pay for all of our patients’ health care costs and only pays for covered benefits. These non-covered items or services will be the responsibility of the patient. The purpose of this notice is to help patients make an informed choice about whether they want to receive these items or services, knowing they will have to pay for them.

Refraction is the most common example of a possible use of the NEMB, helping the patient understand it is an important service even though it is not covered by Medicare. Some patients even insist that refraction be billed and won’t pay unless they see the denial. Another example where the NEMB is useful would be patients electing an advanced technology intraocular lens (IOL), which is an elective procedure to reduce our patient’s dependency on glasses or contact lenses. Of course the standard cataract surgery is covered by Medicare and the extra charges for the advanced IOL are not. The NEMB would be used for those extra charges.

Proper billing for high-risk medications

Q. If we have a patient on plaquenil, what is the best CPT and ICD-9 to bill for visit and additional testing? 

A. In 2011, the American Academy of Ophthalmology (AAO) revised the recommended guidelines for patients using chloroquine (CQ) and hydroxychloroquine (Plaquenil). The updated testing includes a dilated fundus examination to establish a baseline and to rule out maculopathy. Fundus photography can also be considered for documentation. It is also recommended to perform an automated 10-2 visual field in addition to one or all of the following: spectral domain optical coherence tomography (SD-OCT), fundus autofluorescence (FAF) or multifocal electroretinogram (mfERG) if available. Now the question that remains is how to properly bill for this.

First, screening tests are never covered alone so it is important to establish and document medical necessity. The “reason for the visit” of the examination is to diagnose and document any changes that may occur with the use of high risk medications. Use the appropriate CPT codes that most accurately describe the examination (either a 99XXX or 92XXX) with the corresponding ICD-9 code that best describes the condition you are evaluating. A dilated fundus examination is used to detect and document any damage to the optic nerve, macula or retina along with any baseline testing. Fundus photography (92250) is used to establish a baseline to compare for future changes to the macula/retina, while SD-OCT (92134) is used to document changes in the affected area.

The three most-common ICD-9 codes used for patients on high-risk medications such as plaquenil include: 1) The code for the condition (e.g. 714.0, rheumatoid arthritis with plaquenil; 2) V58.69 (long-term use of high-risk medications ; and 3) the E code for the medication (E931.4 for plaquenil). E-codes are supplemental codes that capture the external cause of injury or poisoning or the intent and the place where the event occurred. They are intended to provide data for injury research and prevention strategies and are never used as a primary diagnosis.


These are just a couple of the common questions we receive through askthecodingexperts@excelod.com. Contact us with any other questions. In our upcoming October webinar, we will discuss “Updates on HIPAA and ICD-10” in addition to answering questions from the audience. We hope to “see” you there!

The views expressed are those of the authors and do not necessarily reflect the views of the AOA.

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