Excellence in Optometric Education

Excellence in Optometric Education Excellence in Optometric Education

John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute


Understanding Medicare Understanding Medicare Guidelines - 2013Guidelines - 2013

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John A. McGreal Jr., O.D.John A. McGreal Jr., O.D.

McGreal Educational Institute

Missouri Eye Associates 11710 Old Ballas Rd. St. Louis, MO. 63141 314.569.2020 314.569.1596 FAX [email protected]

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2013 Medicare E/M Guidelines2013 Medicare E/M Guidelines Compliance

– How To Document the Medical Record– How To Select an E/M Codes, eye codes, “S” codes– How To Evaluate your Fees– How To Effectively Co-manage Surgical Cases– How To Increase Revenues– How To Survive an Audit– How To Implement a Compliance Plan

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Medicare Part B DeductibleMedicare Part B Deductible

Deductible (Medicare Part B) – Will increase to $147 in 2013 ($7 more); – thereafter increase by annual percentage increase in Part B

expenditure

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2006 New ICD-9 Codes2006 New ICD-9 Codes Code first diabetes (250.5) 362.03 Nonproliferative diabetic retinopathy NOS 362.04 Mild nonproliferative diabetic retinopathy 362.05 Moderate nonproliferative diabetic

retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema

– Must report with ICD code for diabetic retinopathy 362.01 = background diabetic retinopathy 362.02 = proliferative diabetic retinopathy 362.03 – 362.06

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Timely Claims SubmissionTimely Claims Submission

Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service

This change applies to services furnished after January 1, 2010

Reduces the previous maximum timely filing deadline of 15-27 months

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2011 New CPT Codes2011 New CPT Codes 66761 – Iridectomy/iridotomy by laser surgery per

session (instead of one or more, with GD010) 67220 – Destruction of localized lesion of choroid (ex.

Choroidal neovascularization); photocoagulation, one or more sessions

0191T – Insertion of ant. segment drainage device, without extraocular reservoir, internal approach into TM

0253T – Insertion of ant. segment drainage device, without extraocular reservoir, internal approach, into SC

0192T – Insertion of anterior seg aqueous drainage device, without extraocular reservoir, external approach– Ex. EXPRESS Implant

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New CPT Codes Scanning laser LCDNew CPT Codes Scanning laser LCD 92133 or 92134 and fundus photography are

mutually exclusive in CCI edits– CCI assigned an indicator of “1” instead of “0” which

means there may be medical indications where it is appropriate to unbundle the two codes

There are a limited number of clinical conditions where both techniques are medically necessary and reasonable on the ipsilateral eye

In these situations, both CPT codes may be reported appending the modifier -59 to CPT code 92250

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2012 Deleted CPT Codes2012 Deleted CPT Codes

92120 – Tonography with I&R, perilimbal suction method

92130- Tonography with water provocation

92070 – Fitting of Contact lens for treatment of disease, including supply of lens

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2012 New CPT Codes2012 New CPT Codes 92071 – Fitting of Contact Lens for Treatment of

Ocular Surface Disease– Do not report with 92072– Report supply of lens separately with 99070 or

appropriate supply code 92072 – Fitting of Contact Lens for Management of

Keratoconus, initial fitting– For subsequent fittings, use E/M services or general

ophthalmic services (92xxx)– Do not report with 92071, report supply codes separately

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2012 New ICD-9 Codes2012 New ICD-9 Codes

379.27 Vitreomacular adhesions, associated with AMD, DR, PVD

V19.11 Family history of glaucoma V19.19 Family history of other specified eye

disorder

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2012 New ICD-9 Glaucoma Coding2012 New ICD-9 Glaucoma Coding Given great variability of cost of care & resource

utilization among glaucoma patients, glaucoma care has been targeted for use of potential value-based modifiers in the future– ICD-9 and ICD-10 codes reflect this and will allow

stratification of a patient population Developed by the American Glaucoma Society

(AGS) workgroup, including Drs. Fellman & Mattox– Then enlisted comprehensive ophthalmologists,

optometrists, and a few glaucoma specialists to evaluate and test for accuracy using real cases from Dr. J. Stein at University of Michigan

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2012 New ICD-9 Codes – Glaucoma Stages2012 New ICD-9 Codes – Glaucoma Stages When coding glaucoma subcategories 365.1-365.6

assign an additional code to identify specific stage of glaucoma (365.7)– 365.70 Glaucoma stage, unspecified– 365.71 Mild stage glaucoma– 365.72 Moderate stage glaucoma– 365.73 Severe stage glaucoma– 365.74 Indeterminate stage glaucoma

Includes sequencing instructions to code first the glaucoma, by type– Report new V19.11 history codes where appropriate

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Step One: Code by TypeStep One: Code by Type Only the codes listed here require add-on staging codes

– 365.10 Open angle glaucoma, unspecified– 365.11 Primary open angle glaucoma– 356.12 Low tension glaucoma– 365.13 Pigmentary glaucoma– 365.20 primary angle closure glaucoma, unspecified– 365.23 Chronic or primary angle closure glaucoma, unsp– 365.31 Steroid induced glaucoma– 365.52 Pseudoexfoliation glaucoma– 365.62 Glaucoma associated with ocular inflammations– 365.63 Glaucoma associated with vascular disorders– 365.65 Glaucoma associated with ocular trauma

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Step Two: Add StageStep Two: Add Stage Determine severity of glaucoma in worse eye

– 365.71 Mild (disc abnormalities consistent w glaucoma but no VFD on SAP or Short wave-length doubling perimetry)

– 365.72 Moderate stage (Disc abnormalities consistent w glaucoma and VFD in 1 hemifield, not w/in 5 degrees of fix)

– 365.73 Severe stage (Disc abnormalities consistent w glaucoma VFDs in both hemifields, and/or loss w/in 5 degrees of fix in at least 1 hemifield)

– 365.74 Indeterminate (VFs not performed yet, or patient incapable of VF testing or unreliable or uninterpretable VFs)

– 365.70 Unspecified, stage not recorded in chart Compliance requires documentation of stage in medical

record

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Additional Glaucoma Code ChangesAdditional Glaucoma Code Changes 365.01 Open angle suspect, Low Risk (1-2 risk factors) 365.05 Open angle suspect, High Risk (3+ risk factors)

– Risk factors – family history, race, elevated IOP, disc appearance and thin central corneal thickness

365.02 Primary angle closure suspect (anatomical suspect, narrow angle)

365.06 Primary angle closure without glaucoma damage (defined as angle damage such as synechia or high IOP, but w/o optic nerve damage)

365.23 Chronic angle closure glaucoma (angle damage plus optic nerve damage)

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2012 SCODI Update2012 SCODI Update

Medicare carriers have updated their Local Coverage Decisions (LCDs) for scanning computerized digital ophthalmic imaging (SCODI) to include covered diagnosis codes for diagnostic screening of patients taking Hydroxychloroquine (Plaquenil).

Some indicate frequency and some specify spectral domain only

Covered ICD-9 codes are V58.69 High Risk Medications, Current use, and V67.51, Following Completed Treatment with High Risk Medications

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2013 Other Changes2013 Other Changes Cataract surgery fees reduced for 66982 & 66984 by

13% Physician Compare Website – includes name,

specialty, education, participation status, status in PQRS & e-prescribing, board certification, additional foreign language, hospital affiliation, EHR incentive program

ICD-9 – NO CHANGES!

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Physician Value-Based Payment ModifierPhysician Value-Based Payment Modifier CMS will adjust payment to some physicians based

on quality & resource use beginning in 2015 and all physicians by 2017– Now applies only to groups of 100 or more (originally

25)– Smaller groups (2-99) remain unaffected until 2017

3% payment penalty to hospitals began in 2012 for re-admission rates higher than national average– Heart failure– Pneumonia– Myocardial infarction

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Reduction in Diagnostic TestingReduction in Diagnostic Testing CMS will decrease payment by 20% of technical

component of second and subsequent diagnostic tests furnished by same physician (or physicians in same group) to same patient on same day– Originally set at 25%– A diagnostic service refers to any diagnostic test that has

a technical & professional component CMS indicated they will closely monitor practice

changes to bypass multiple payment reductions

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Reduction in Diagnostic TestingReduction in Diagnostic Testing 76510 92060 92228 92285 76511 92081 92235 92286 76512 92082 92240 76513 92083 92250 76514 92132 92270 76516 92133 92275 76519 92134 92283 92125 92136 92284

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PQRI Name Change to PQRSPQRI Name Change to PQRS CMS continues incentive payments in 2013

– www.cms.gov/PQRI/15_MeasuresCodes.asp Successful PQRS reporters earn 0.5% in 2013 Must report on at least 3 measures 50% of the time

– Decrease from 80% in 2010 Report for full year (Jan1-Dec31, 2013) Incentive payments for years 2014 will be 0.5% 2015

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PQRS 2013PQRS 2013

In 2015 a 1.5% PQRS payment penalty will be applied, in 2016 this increases to 2.0%– 2013 PQRS participation used to determine cuts in 2015– Participation means attempting to report at least one PQRS

measure between Jan 1 –Dec 31 2013 Glaucoma staging codes removed Measure 124: Health Information Technology has

been eliminated

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OIG Audits / Work PlanOIG Audits / Work Plan Ophthalmological services – 92xxx codes

– Reviewing claims during 2011 – 6.8 billion in claims by eye MDs & ODs– Focus on 92004/92014, other 92- included

E/M Services: Use of modifiers– Modifiers -25– Bilateral intravitreal injections

Sequestration – 2% payment reductions across the board in Medicare claims beginning April 1, 2013– Includes a 2% reduction in EHR incentive bonus

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OIG Work PlanOIG Work Plan Ophthalmological services – New

– Reviewing claims during 2011 – $6.8 Billion paid to ophthalmologists & optometrists in 2011– 8.31% of all claims paid to all physicians in all specialties– 92004 was 12th highest paid code used in all specialties– 66984 was 5th highest paid code – 99xxx E&M codes not included, not specialty specific

E/M Services: Use of modifiers– Modifiers -25– Bilateral intravitreal injections

http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf

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OIG Work PlanOIG Work Plan Rank CPT Services 5 66984 Cat-IOL 12 92014 Comp eye exam, est pt 26 92012 Interm eye exam, est pt 31 92135 Scanning laser 52 92004 Comp eye exam, new pt 63 66984 Cat-IOL, complicated 67 00142 Anesthesia for proc, eye, lens 73 92083 Visual field, full 103 92250 Fundus photography 141 67228 Treatment of exten or prog

retinopathy 148 15823 Blepharoplasty 178 92136 Ophthalmic biometry w IOL power

calc

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Recovery Audit Contractors RACRecovery Audit Contractors RAC Evaluating RAC performance 2010 & 2011 Completed 3 year demonstration project in 2012 Congress will mandate a nationwide implementation of

a permanent RAC program for Medicare part A & B Mandates by Tax Relief & Health Care Act 2006 and

Affordable Care Act Tool used include comparative billing reports

– Shows specific provider billing patterns compared to peers

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Health Insurance Portability and Health Insurance Portability and Accountability Act of 1996Accountability Act of 1996

President Clinton & USAG J. Reno– #2 priority: prosecution of health care fraud– $104 Million: Appropriations to HHS– $70 Million: OIG– $47 Million: FBI fraud investigation unit– Criminal offenses expanded– $10,000 fine / line item violation– suspension of payment and participation from program– Yielded $23 return on every $1 spent in 1997

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Dead Doctors Billing Scams 2000-2007Dead Doctors Billing Scams 2000-2007

478,500 false claims 16,500 dead physicians $92.8 million in payments just by Medicare 16% made by doctors dead for more than 10 years

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Qui Tam RelatersQui Tam Relaters Amendment to False Claims Act of 1986 Encourages private individuals to sue in the

government’s behalf Whistleblowers - 30% of recoveries

– $1 Billion paid since 1987 in Qui Tam actions Compliance Plan

– Eliminates aggressive or conservative billing philosophies– Removes incentives for whistleblowers– Improves collections while reducing audit risks

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Top 10 Procedure Codes – Optometry Top 10 Procedure Codes – Optometry Missouri / Jan-June 2007 / 495 Providers Missouri / Jan-June 2007 / 495 Providers

92014 $1,369,645 99214 $ 634,210 92004 $ 562,906 92012 $ 551,297 99213 $ 541,616 66984 $ 395,125 92250 $ 339,862 92083 $ 277,708 99203 $ 199,510 92135 $ 195,427

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2012 Comprehensive Error Rate Testing 2012 Comprehensive Error Rate Testing (CERT)(CERT)

There has been a HUGE increase in CERT audits of E/M services since October 2011

From April 2009-May 2010, E/M services accounted for 28 billion in Medicare Part B payments– Estimated 8.4% billed incorrectly

Providers encouraged to review 1997 E/M Guidelines for compliance

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2011 CMS Optometry Probe Results2011 CMS Optometry Probe Results

Prepayment review of 100 services from 100 claims Probe: CPT 99213 (random) Results

– 66% allowed as billed– 34% denied

23% No documents submitted 5% Services not documented in medical record 3% Non-covered services 3% Not medically necessary

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Code Set Adoption in HIPAACode Set Adoption in HIPAA CPT-4: Current Procedure Terminology CDT: Code on Dental Procedures and Nomenclature ICD-9-CM (Volume 1,2): International Classification of

Diseases (Implementation of ICD-10 is October 1, (Implementation of ICD-10 is October 1, 2014!!)2014!!)

ICD-9-CM (Volume 3): inpatient disease codes NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding

System

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Medicare – Just Give Me The NumbersMedicare – Just Give Me The Numbers Longevity Revolution

– First year of Baby Boomers hitting 65 years of age– 10,000/day turn 65 years of age– An individual turns 60 years of age every 8 seconds– If you live until age 65, average life expectancy is age 84

47, 672,971 Medicare beneficiaries in US– 15% of total population

Cataract surgery is the most common surgical procedure in US in Medicare beneficiaries– Also boasts best outcomes– Lowest complication rate

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Medicare – Distribution by Age (2004)Medicare – Distribution by Age (2004)

65-69 23.2 % 70-74 19.9 % 75-79 17.3 % 80-84 12.9 % 85+ 11.0 %

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AOA Optometric Practice Profiles 2005AOA Optometric Practice Profiles 2005 VSP – 21% Other vision plans – 8% Medicare – 19.1% (fastest growing share of revenues) Medicare HMOs – 3% Medicaid – 7% HMOs (private sector) – 8% Out of pocket – 35% Respondents - 90% self-employed, 47% solo, 24%

group, 86% male, mean years in practice 24.2 years

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INTRODUCTIONINTRODUCTION CMS CPT ICD Medicare Major Medical E/M Coding (99XXX) Eye Coding (92XXX) Special Ophthalmic Codes

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E/M GUIDELINESE/M GUIDELINES New/Established Patient Chief Complaint History of Present Illness Family History Past History Social History

– New additions level of education, sexual history, marital status/living arrangements

Review of Systems Time

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E/M DESCRIPTORSE/M DESCRIPTORS

History * Examination* Medical Decision Making* Counseling Coordination of Care Nature of the Presenting Problem Time

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CATEGORIES OF SERVICECATEGORIES OF SERVICE Office Visits (E/M Codes)

– New 99201-99205– Estab 99211-99215

Office Visits (Eye Codes)– New 92002-92004– Estab 92012-92014

Consultations (E/M Codes)– ELIMINATED for Medicare, Medicaid, Tricare and

Medicare Advantage HMOs and when any of these are secondary payors

– Can still be used for other commercial plans

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SELECTING AN E/M LEVELSELECTING AN E/M LEVEL

Identify Category of Service Identify Extent of History Taking Identify Extent of Examination Identify Complexity of Medical Decision Making Review E/M Descriptors

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E/M CODING - OFFICE VISITSE/M CODING - OFFICE VISITS

New Patient (3 of 3)– 99201 - PFH / PFE / SDM / 10– 99202 - EFH / DFE / SDM / 20– 99203 - DH / DE / LDM / 30– 99204 - CH / CE / MDM / 45– 99205 - CD /CE / HDM / 60

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E/M Coding - Office VisitsE/M Coding - Office Visits

Established Patient (2 of 3)– 99211 - Minimal / 5– 99212 - PFH / PFE / SDM / 10– 99213 - EFH / EFE / LDM / 15– 99214 - DH / DE / MDM / 25– 99215 - CH / CE / HDM / 40

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DOCUMENTATION OF HISTORYDOCUMENTATION OF HISTORY

Problem Focused History (PFH)– CC / 1-3 HPI

Expanded Problem Focused History (EPF)– CC / 1-3 HPI / Ocular ROS

Detailed History (DH)– CC / 4 HPI / Ocular ROS / ROS-2 / 1 OF 3 PFSH

Comprehensive History (CH)– CC / 4 HPI / Ocular ROS / ROS-10 / 3 OF 3 PFSH (NEW)

OR 2 OF 3 PFSH (ESTAB)

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Eye Examination DocumentationEye Examination Documentation

VA / CVF / Pupils & Iris / Adnexa Bulbar & Palp Conjunctiva EOM SLE: Cornea / Lens /AC IOP / Optic Nerve / Posterior Segment Neurologic: Orientation (Time / Place / Person) Psychiatric: Mood & Affect (Depression /Anxiety

/Agitation)

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DOCUMENTATION OF EXAMINATIONDOCUMENTATION OF EXAMINATION Problem Focused Exam (PFE)

– Limited Exam / l - 5 Elements Expanded Problem Focused Exam (EPF)

– Limited Exam / 6 Elements Detailed Exam (DE)

– Extended Exam / 9 Elements Comprehensive Exam (CE)

– Complete Single System Exam– All Elements

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Medical Decision MakingMedical Decision Making Straightforward (SF)

– # Dx / Rx Options - Min / Data - Min / Risk - Min Low Complexity (LC)

– # Dx / Rx Options - Lim / Data - Lim / Risk - Low Moderate Complexity (MC)

– # Dx / Rx Options - Mult / Data - Mod / Risk -Mod High Complexity (HC)

– # Dx / Rx Options - Ext / Data - Ext / Risk - High

Comprehensive Ophthalmological Service Comprehensive Ophthalmological Service 92004 / 9201492004 / 92014

Complete system evaluation, Need not be performed at one session Integrated services where med decision making cannot

be separated from examination methods Itemization of service components, such as slit lamp

examination, keratometry, routine ophthalmoscopy retinoscopy, tonometry, or motor evaluation is not applicable

Comprehensive Ophthalmological Service Comprehensive Ophthalmological Service 92004 / 9201492004 / 92014

Includes history, medical observation, external & ophthalmoscopic examinations, gross visual fields, sensorimotor examination

Often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry

Always includes initiation of diagnostic and treatment programs

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Comprehensive Ophthalmological Comprehensive Ophthalmological ServiceService

92004/9201492004/92014 Always includes initiation of diagnosis and treatment

programs– includes the prescription of medication, and arranging for

special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services

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Intermediate Ophthalmological ServiceIntermediate Ophthalmological Service92002 / 9201292002 / 92012

Evaluation of new or existing condition, complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis

Integrated services where med decision making cannot be separated from examination methods

Includes history, medical observation, external & adnexal, & other diagnostic procedures as indicated; may include use of mydriasis for ophthalmoscopy

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2004 New HCPCS Codes2004 New HCPCS Codes “S” codes are useful for some private insurers Medicare and other federal payers do not recognize

them They are useful when CPT does not have a code to

accurately describe the service (i.e. LASIK, PTK, PRK, corneal topography) or for invoicing self-pay patients.

They specifically describe “routine exams” including refractions and permit a different charge

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HCPCS “S” CodesHCPCS “S” Codes

S0620 Routine ophthalmologic exam including refraction; new patient

S0621 Routine ophthalmologic exam including refraction; established patient

S0625 Digital screening retina

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2013 Medicare Physician Fee Schedule2013 Medicare Physician Fee Schedule Physicians faced a 26.5% cut in payment effective

January 1, 2013 based on Sustainable Growth Formula American Taxpayer Relief Act of 2013 – signed into

law on January 2, 2013– Prevented negative fee update– 0% update until 12/31/13– Contractors may hold claims with January 2013 dates for 10

days – Carriers to post MPFS on websites by January 23, 2013

This is the 12th time the SGF resulted in a payment cut, although all have been averted by Congress except 2002

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2013 Medicare Fee Schedule2013 Medicare Fee Schedule

99201 $ 43.03 99211 $ 19.93 99202 $ 73.21 99212 $ 43.03 99203 $ 106.51 99213 $ 71.76 99204 $ 162.50 99214 $ 105.16 99205 $ 201.26 99215 $ 140.81

92002 $ 81.34 92012 $ 85.66 92004 $ 148.59 92014 $123.76

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RefractionRefraction9201592015

Non-covered service Can be billed to beneficiary

– failure to do so results in lost revenues Reminders

– Charge only for “Rx-able” refractions– Do not forget to charge for the final refraction when changing

spectacles in a post-operative cataract patient

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GonioscopyGonioscopy9202092020

Bilateral Requires documentation

– describe visible angle structures No limitations to diagnostic groups in most states Fee $ 27.12

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Visual Field 9208xVisual Field 9208x

Bilateral Requires Interpretation

– separate report form– narrative in body of medical record, on date of service

Fee (-81) / $ 34.29 Fee (-82) / $ 49.20 Fee (-83) / $ 65.03

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Extended OphthalmoscopyExtended Ophthalmoscopy92225 / 9222692225 / 92226

Unilateral Initial (-225) vs. Subsequent (-226) Implies detailed, extra ophthalmoscopy

– document fundus lenses used Modifiers RT /LT Requires retinal drawings & interpretation

– sizes, colors and dimensions carrier specific Fee 92225 ($ 27.13) 92226 ($ 24.38)

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Fundus PhotographyFundus Photography9225092250

Bilateral Not Bundled Requires Interpretation Fee $ 69.81

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External Ocular PhotographyExternal Ocular Photography9228592285

Report for documentation of medical progress– Ex.: close-up photography, slit lamp photography,

goniophotography, stereo-photography Bilateral Not Bundled Requires Interpretation and report Fee $ 20.79

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Special Anterior Segment PhotographySpecial Anterior Segment Photography9228692286

With specular endothelial microscopy and cell count– Ex: Konan specular microscope

Bilateral Not Bundled Requires Interpretation and report Fee $ 37.95

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364.00-364.04 iridocyclitis 364.10-364.11 chronic iridocyclitis 364.21 Fuch’s heterochromic iridocyclitis 364.22 glaucomatocyclitic crisis 364.23 lens induced iridocyclitis 364..24 VKH syndrome 364.51 essential iris atrophy 364.52 iridoschisis 364.53 pigmentary iris degeneration 364.54 pupillary margin degeneration

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364.55 Miotic Cysts of pupil margin 364.56-364.61 degenerative changes of anterior

structures 366.21-23 Traumatic cataract 366.32 cataract in inflammatory disorder 366.33 cataract in ocular neovascularization 371.20-24 corneal edemas 371.32-33 folds or rupture in descemet’s membrane 371.50, -.57,-.58, corneal dystrophy

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371.82 corneal edema due to contact lens 379.31 aphakia 379.32 subluxation of lens 379.33 anterior displacement of lens 743.20-23 buphthalmos 906.5 late effect of burn of eye/face 940.2 alkaline burn of cornea/conj 940.3 acid burn of cornea/conj 940.4 other burn of cornea/conj V42.5 cornea replaced by transplant

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996.51 mechanical complication of prosthetic corneal graft 996.60 infection/inflammation due to unspecified implant and

graft 996.69 complication of other implant or graft 998.89 complication of other transplanted organ 998.59 other postoperative infection 998.82 cataract fragments in eye following cataract surg V53.1 fitting & adjusting specs or CL after intraocular surgery

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Tear Osmolarity TestingTear Osmolarity Testing8386183861

Unilateral– Paired or cross walked to code 84081

Applies to TearLab’s Osmolarity Device– Novel “Lab-on-a-chip”– Point of care, 50nl sample of tear fluid– Sample-to-answer in less than 30sec– CLIA waiver granted

Requires Interpretation & report Fee $23.25

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Computerized Corneal TopographyComputerized Corneal Topography9202592025

Bilateral or unilateral Requires interpretation & report No limitations to diagnostic groups in most states Fee $ 37.56

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92025 Corneal Topography92025 Corneal Topography ICD-9 Codes that Support Medical Necessity

– 367.22* Irregular astigmatism– 371.00 Corneal Opacity Unspecified– 371.23 Bullous Keratopathy– 371.50 Hereditary Corneal Dystrophy Unspecified– 371.52 Other Anterior Corneal Dystrophy– 371.57 Endothelial Corneal Dystrophy– 371.60 Keratoconus Unspecified– 371.61 Keratoconus Stable Condition

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92025 Corneal Topography92025 Corneal Topography ICD-9 Codes that Support Medical Necessity

– 371.62 Keratoconus Acute Hydrops– 372.40 Pterygium Unspecified– 996.51 Mechanical Complication Prosthetic Corneal Graft– V42.5 Cornea Replaced by Transplant– V45.61* Cataract Extraction Status– V45.69* Other States Following Surgery of Eye /Adnexa– *367.22 must be accompanied by V45.61 or V45.69– *V45.61 must be accompanied by 367.22– *V45.69 must be accompanied by 367.22

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic ImagingDiagnostic Imaging

9213292132 Unilateral or bilateral Applies to anterior segment evaluations

– Carl Zeiss / Optical Coherence Tomography (Cirrus)– Optovue / (RTVue, iVue)

Requires Interpretation & report Fee $ 35.66

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging 92132Diagnostic Imaging 92132

190.0, 190.3 Malig neoplasm of eyeball, ecept conj, cornea, retina or choroid

190.3 malignant neoplasm of conjunctiva 190.4 Malignant neoplasm of cornea 190.6, 190.8 Malignant neoplasm of choroid, other sites 224.0 Benign neoplasm of eyeball except conjunctiva, cornea,

retina, or choroid 224.3 Benign neoplasm conjunctiva 224.4 Benign neoplasm of cornea 224.6, 224.8 Benign neoplasm of choroid, other sites 360.51 Foreign body in anterior chamber (magnetic) 360.61 Foreign body in anterior chamber

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364.51 Essential iris atrophy 364.53 Pigmentary iris degeneration 364.54 Degeneration of pupillary margin 364.71 Posterior synechia 364.72 Anterior synechia 364.75 Pupillary abnormalities 364.76 Iridodialysis 364.77 Recession of chamber angle 364.82 Plateau iris syndrome 365.02 Anatomical narrow angle 365.20-365.89 Primary angle closure and other glaucomas

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366.16 Nuclear sclerosis 370.00-370.07 Corneal ulcers 371.00-371.09 Corneal opacities 371.20-371.24 Corneal edema (includes due to CL) 371.57 Endothelial dystrophy 372.40-372.45 Pterygium 379.31 Aphakia 379.32 Subluxed lens 996.51 Mechanical complication of corneal graft 996.53 Mechanical complication of ocular lens prosthesis 996.69 Infection & Inflammation due to other int prosthetic

device implant or graft

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Fitting CL for Ocular Surface DiseaseFitting CL for Ocular Surface Disease9207192071

Unilateral; Use –RT/-LT or -50 Do not report 92071 in conjunction with 92072 Report supply of lens separately with 99070 or

appropriate supply code Fee $33.65

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Fitting CL for Management KeratoconusFitting CL for Management Keratoconus9207292072

Initial fitting– For subsequent fittings, report E/M services or general

ophthalmological services Do not report 92072 in conjunction with 92071 Report supply of lens separately with 99070 or

appropriate supply code Unilateral payment; Use –RT/-LT or -50 Fee $126.11

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Serial TonometrySerial Tonometry9210092100

Bilateral Requires Interpretation & Report

– Example: Angle closure glaucoma– multiple measurements over time

Fee $ 79.89

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PachymetryPachymetry7651476514

Bilateral Measurement of central corneal thickness (CCT) proven

by Ocular Hypertension Treatment Study (OHTS) to be standard of care in diagnosis and management of glaucoma, glaucoma suspect and ocular hypertension

Also billable for keratoconus, corneal transplants, cataracts with corneal dystrophies, guttata, edema

Requires Interpretation & Report Fee $ 14.39

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9213392133 Unilateral or bilateral Applies to glaucoma or optic nerve evaluations

– Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis)– Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)– Optovue / (RTVue, iVue)– Marco / Retinal Thickness Analyzer (RTA)


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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92133Diagnostic Imaging - 92133 360.30-360.34 Hypotony and flat chamber 354.22 Glaucomatocyclitic crises 365.00-365.04 Glaucoma suspect, OCHTN 365.10-365.15 Open angle glaucoma 365.20-365.24 Primary angle closure glaucoma 365.31-365.32 Steroid induced glaucoma 365.41-365.44 Glauc w chamber anomalies 365.51 Phakolytic glaucoma 365.52 Pseudoexfoliation glaucoma 365.59 Glaucoma assoc w lens disorders

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92133Diagnostic Imaging - 92133 365.60-365.65 Glaucoma assoc w ocular trauma 368.40-368.45 Visual field defects 376.00-376.9 Acute inflammations of the orbit 377.00-377.03 Papilledemas 377.04 Foster-Kennedy 377.10 Optic atrophy 377.14-377.16 Glaucomatous atrophy 377.21 Drusen 377.22 Crater like holes of optic disc 377.23 Coloboma of optic disc

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92133Diagnostic Imaging - 92133 377.24 Pseudopapilledema 377.41-377.49 Ischemic optic neuropathies 377.51-377.54 Disorders of optic chiasm assoc w pit

neoplasms or inflammatory disorders 377.61-377.63 Disorders of other visual pathways assoc

w neoplasms or inflammations 743.20-743.22 Buphthalmos 743.57-743.58 Cong anomalies of optic disc & vasc

anomalies

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9213492134 Unilateral or bilateral Applies to retinal evaluations

– Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis)– Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus)– Optovue / (RTVue, iVue)– Marco / Retinal Thickness Analyzer (RTA)


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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92134Diagnostic Imaging - 92134 190.6, 190.8 Malignant neoplasm choroid 224.6, 224.8 Benign neoplasm choroid or other sites 360.11 Sympathetic uveitis 360.21 Progressive high (degenerative) myopia 360.30-360.34 Hypotony, flat chamber 361.00-361.07 Retinal detachments 361.10 Retinoschisis 361.2 Serous retinal detachment 361.81 Traction detachment 362.01-362.06 Diabetic retinopathy, background to severe NPD

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92134Diagnostic Imaging - 92134 362.07 Diabetic macular edema 362.10-362.18 BDR, retinal vasculitis 362.31-362.32 Central or branch retinal artery occlusion 362.35-362.37 Central or branch retinal vein ooclusion 362.40-362.43 Retinal layer separation, hemor detach RPE 362.50- 362.77 Macular degeneration, retinal dystrophies

involving Bruch's membrane 362.81 Retinal hemorrhage 362.82 Retinal exudates and deposits 362.83 Retinal edema

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Scanning Computerized Ophthalmic Scanning Computerized Ophthalmic Diagnostic Imaging - 92134Diagnostic Imaging - 92134 363.00-363.08 Focal chorioretinitis 363.10-363.15 Disseminated chorioretinitis 363.20-363.35 chorioretinitis unspecified 363.43 Angioid streaks 363.61 Choroidal hemorrhage 363.63 Choroidal rupture 363.70-363.72 Choroidal detachmts 376.00-376.9 Acute inflammations of orbit 379.11-379.19 Scleral ectasia and other scleral disorders 379.21-379.29 Vitreous degenerations & other disor of vitreous 921.3 Contusion of eyeball

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Correction TrichiasisCorrection Trichiasis67820*67820*

Epilation By forceps ICD-9

– 374.05 Trichiasis without entropion– 374.01 Senile entropion

Global days - 000 Fee $ 51.75

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Removal of Foreign BodyRemoval of Foreign Body65205*65205*

External Eye, Conjunctiva– superficial– scleral, non-perforating

ICD-9– 930.18 FB in cul-de-sac


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External Eye, Conjunctiva– embedded (includes concretions)– subconjunctival– scleral, non-perforating

ICD-9– 930.18 FB in other sites or combined sites


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External Eye, Corneal– with Slit Lamp

ICD-9– 930.0 FB in cornea


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Sensorimotor ExaminationSensorimotor Examination9206092060

Quantitative measurement of ocular deviation – document all major fields of gaze

Bilateral Requires interpretation and report Fee $65.27 92065 – Orthoptic and / or pleoptic training, with

continuing medical direction and evaluation Fee $ 53.98

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Dilation of Lacrimal PunctaDilation of Lacrimal Puncta68801*68801*

With or Without Irrigation ICD-9

– 375.22 Epiphora, insufficiency of drainage– 375.42 Chronic Dacryocystitis– 375.52 Stenosis, Lacrimal Punctum– 375.56 Nasolacrimal Duct Obstruction

Fee $ 128.04

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Punctal Occlusion By PlugPunctal Occlusion By Plug6876168761

Temporary (collagen) or Permanent (Silicone) Payment is per puncta (modifiers required)

– E1=left upper E3=right upper– E2=left lower E4=right lower

Global period - 10 days Supply code-included in procedure code, not separately

billable Fee $151.71

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Punctal Occlusion By PlugPunctal Occlusion By Plug6876168761

ICD-9– 370.21 Punctate Keratitis– 370.23 Filamentary Keratitis– 370.34 Exposure Keratitis– 370.80 Other forms of Keratitis– 370.90 Unspecified Keratitis– 371.42 Recurrent Corneal Erosion– 374.41 Eyelid Retraction– 375.15 Unspecified Tear Film Insufficiency– 710.20 Sicca Syndrome; use additional systemic manif. code

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ModifiersModifiers– 79 Inside post-operative global period– 50 Bilateral Procedure– 24 Unrelated Service / Same Doctor– 79 Inside Global Period– 25 Separate Service / Same Doctor / Same Day – 52 Reduced Service / Informational / Not Reduced Fee– 54 Surgical Care Only– 55 Post-Op Care Only– 51 Multiple Procedures– RT / LT Right / Left– E 1- E4 Identifies Puncta– 52 Reduced service

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Comanagement of SurgeryComanagement of Surgery Procedures / 66984 / $ 658.82 Global Periods - 90 days Value - up to 20% MD name and NPI Modifiers (-54 on MD claim, -55 on OD claim and RT/LT) Range Dates – from transfer date to end of 90 day global Rules - Medicare Transfer Agreement in MD record Correspondence Legal/Political/Inter-professional Issues

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Complicated Cataract Surgery Complicated Cataract Surgery 66982 66982

New CPT code for 2001 / $ 818.06 Extracapsular cataract extraction with insertion of

IOL, complex, requiring devices or techniques not generally used in routine cataract surgery– 2-3% of all cataract surgeries involve extraordinary work

iris expansion devices, suture support for IOL, posterior capsulorrhexis, small pupil, subluxed lens, Pseudoexfoliation, trauma, Marfan’s, glaucoma, uveitis

pediatric population Advanced, white, hard cataract

Case Studies for Clinical Case Studies for Clinical CorrelationCorrelation

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CASE 1: CataractCASE 1: Cataract CPT / ICD

– 92015 / Myopia (367.1) = $20.00– 99203 / Cataract (366.16) = $100.00 or 92004 ($135)– Total $120.00 or +

Rx: Spectacles RTO: 1YR CPT / ICD

– 92015 / Myopia (367.1) = $20.00– 99214 / Cataract (366.16) = $100.00 or 92014 ($110)– Total $120.00 or +

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CASE 2: BlepharoconjunctivitisCASE 2: Blepharoconjunctivitis CPT / ICD

– 99213 or 92012 / Blepharitis (373.00) = $60.00 or $75.00 Rx: Bacitracin Oint hs / Tobradex qid / Lid Hygiene /

AFTs RTO: 1 WK CPT / ICD

– 99212 / Blepharitis (373.00) = $40.00– Total $100.00 or $115

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CASE 3: Allergic ConjunctivitisCASE 3: Allergic Conjunctivitis CPT / ICD

– 99213 or 92012 / Conjunctivitis allergic (372.14)– $60.00 or $75.00

Rx: Pataday QD / Cold Packs / AFTs RTO: 1 WK CPT / ICD

– 99212 or 92012 / Conjunctivitis, allergic (372.14) = $40.00 or $75.00

– Total $100.00 or $150.00

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CASE 4: Rosacea (Skin & Eye)CASE 4: Rosacea (Skin & Eye) CPT / ICD

– 99213 or 92012 Meibomianitis (373.12) / Acne Rosacea (695.30) = $60.00 or $75.00

– 92285 / (370.01) Marginal keratitis = $25.00– Total $ 85.00 or $100.00

Rx: Zylet QID / Lid Hygiene (foams) / Doxycycline 50mg BID / MetroCream 0.75% BID RTO: 2 D

CPT / ICD– 99212 or 99213 / Meimbomianitis (373.12) = $40.00 or $75.00– Total $125.00 or 175.00

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Case 5 : Conjunctival Foreign BodyCase 5 : Conjunctival Foreign Body CPT / ICD

– 99213-25 / SPK (370.21) = $60.00 or 92012 ($75)– 92285 / SPK (370.21) = $25.00– 65210 / Conj FB (931.8) = $65.00– Total $150.00 or $165

Rx: Acular QID / AFTs / Besivance TID RTO: 1 Day / PRN

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CASE 6: Corneal Foreign BodyCASE 6: Corneal Foreign Body CPT / ICD

– 99213-25 / Abrasion (918.1) = $60.00 or 92012 ($75)– 99285 / Abrasion (918.1) = $25.00– 65222 / Corneal Foreign Body (930.00) = $70.00– Total $ 155.00 or $170

Rx: Acular LS QID / Zymar QID / Patch +/- Ibuprofen 400mg

RTO: 1 Day

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CASE 7: Misdirected LashesCASE 7: Misdirected Lashes CPT / ICD

– 99213-25 / SPK (370.21) = $60.00 or 92012 ($75)– 92285 / SPK (370.21) = $25.00– 67820/ Trichiasis w/o entropion (374.05) = $50.00– Total $135.00 or $150

Rx: Bromday qd / AFTs RTO: 1 Day / PRN

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CASE 8: Corneal ErosionCASE 8: Corneal Erosion CPT / ICD

– 99213 / Recurrent Corneal Erosion (371.42) = $60.00– 92071 / Recurrent Corneal Erosion (371.42) = $70.00– Total $130.00

Rx: Vigamox TID / Nevanac TID / Bandage SCL / Doxycycline 50mg qd optional / FreshKote TID

RTO: 1 Day CPT / ICD

– 99212 or 92012 / Recurrent Corneal Erosion (371.42) = $40.00 or $75.00

– Total $170.00 or $205.00

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CASE 9: Bacterial KeratitisCASE 9: Bacterial Keratitis CPT / ICD

– 99213 or 92012 / Bacterial Keratitis (370.03) = $60.00 or $75.00

– 92285 / Bacterial Keratitis (370.03) = $25.00– Total $85.00 or $100.00

Rx: IQUIX q2h RTO: 1 Day E/M: 99212 or 99213 or…..? Can add anterior OCT

– Total $145.00 and up

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CASE 10: Central Serous RetinopathyCASE 10: Central Serous Retinopathy CPT / ICD

– 99213 / Central serous retinopathy (362.41) = $60.00– 92225-LT / Central serous retinopathy (362.41) = $20.00– 92250 / Central serous retinopathy (362.41) = $70.00– Total $150.00 (Option to do OCT and use -59 on photo*)

Rx: Observation or Bromday qd RTO: 1 Mos CPT / ICD

– 99213 / Central serous retinopathy (362.41) = $60.00– 92226-LT / Central serous retinopathy (362.41) = $20.00– 92134 / Central serous retinopathy (362.41) = $50.00– Total $270.00

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CASE 11: Epiretinal MembraneCASE 11: Epiretinal Membrane CPT / ICD

– 99214 / Macular puckering (362.56) = $60.00– 92225-LT / Macular puckering (362.56) = $20.00– 92250 / Macular puckering (362.56) = $70.00– Total $160.00 (Option to do OCT and use -59 on photo)*

Rx: Observation RTO: 1 Mos CPT / ICD

– 99213 / Macular puckering (362.56) = $60.00– 92226-LT / Macular puckering (362.56) = $20.00– 92134 / Macular puckering (362.56) = $40.00– Total $280.00

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CASE 12: Macular Degeneration/DryCASE 12: Macular Degeneration/Dry CPT / ICD

– 99203 / Age Related Macular Degeneration (362.51) = $100.– 92225-RT, 92225-LT / (362.51) = $40.00– 92250 / (362.51) = $70.00– Total $210.00

Rx: Amsler Grid (or PHP) / MPOD (cash) / Vitamins (Cash) / Genetic testing to set risk (Information and frequency issues)

RTO: 6 Mos or sooner CPT / ICD

– 99213 / 92134 / (362.51) = $100.00– Total $310.00 plus MPOD and Vitamins

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CASE 13: Macular Degeneration/WetCASE 13: Macular Degeneration/Wet CPT / ICD

– 99203 / Age Related Macular Degeneration (362.52) = $100.– 92225-RT, 92225-LT / (362.52) = $40.00– 92250 / (362.51) = $70.00– Total $210.00 (Option for OCT use -59 on photo)*

Rx: Amsler Grid (or PHP or PHP Home) / MPOD (cash) / Vitamins / Consult Retina for IVFA and treatment

RTO: 6 Mos CPT / ICD

– 99213 / 92134 / 92082 (PHP) /(362.52) = $150.00– Total $360.00 insurance plus MPOD testing and Vitamin sales

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CASE 14: High Risk MedicationsCASE 14: High Risk Medications CPT / ICD

– 99213 / Rheumatoid Arthritis (714.0), High Risk Medical Treatment (V58.69) = $60.00

– 92226-RT, 92226-LT / (714.0, V58.69) = $40.00– 92083 / (714.0, V58.69) = $70.00– 92134 / (V58.69) = $45– Total $215.00

Rx: Observation RTO: 6 Mos CPT / ICD

– Same as above = $215.00 (some carriers allow SD-OCT once per year)– Total $430.00

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CASE 15: DermatitisCASE 15: Dermatitis

CPT / ICD– 99213 or 92012 / Dermatitis (373.32) = $60.00 or $75.00– 92285 / (373.32) = $25.00– Total $85.00 or $100

Hydrocortisone 1.0% QID / Cold Packs RTO: 1 WK CPT / ICD

– 99212 / (373.32) = $40.00– Total $125.00 – $140.00

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CASE 16: Glaucoma SuspectCASE 16: Glaucoma Suspect CPT / ICD

– 99214 / Glaucoma Suspect Low Risk (365.01) = $100.00 or 92014 ($110)

– 92020 / (365.01) = $25.00– 76514 / (365.01) = $15.00– 92250 / (365.01) = $70.00– 92083 / (365.01) = $80.00

CPT / ICD – 99213 or 92012 / (365.01) = $60.00 or $75.00– 92133 / (365.01) = $50.00– Total $400.00 or $425.00

Dx: Complete testing battery in two visits Rx: Initiate or continue treatment or consultation-MD Use V58.69 in addition to ICD code when changing medications

in a glaucoma patient

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CASE 17: Neovascular glaucomaCASE 17: Neovascular glaucoma CPT / ICD

– 92012 / Glaucoma assoc w vascular disorders (365.63 / Severe stage 365.73) = $75.00

– 92132 / goniosynechia (364.73) = $35.00– Total $108.00

Rx: Combigan BID OS, PredForte BID OS RTO: 1 WK E/M: 99213 or….plus gonioscopy.?

– Total $170.00 and up

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CASE 18: Punctal Occlusion of Dry EyeCASE 18: Punctal Occlusion of Dry Eye Dx: Documentation: Narrative & Shirmer Strips CPT / ICD Temporary Collagen Plugs

– 99214-25 / Dry Eye Syndrome (370.33) = $100.00– 68761-E2 / (370.33) = $135.00– 68761-E4 / (370.33) = $135.00 (Paid at 50% allowable)– Total $300.00

E/M: Permanent Silicone Plugs– 99212-25, 68761-E2, 68761-E4 / (370.33) = $240.00

RTO: >10 Days After Permanent Punctal Occlusion Total $540.00

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CASE 19: Cataract Co-ManagementCASE 19: Cataract Co-Management CPT / ICD

– 66984-55, RT or LT / 366.16– Date of Service-is date of surgery– Range Dates-starts on date of transfer of care from MD to

OD, ends 90 days from date of surgery– MD name and NPI

Rx: Post-Operative Care RTO: Outcome dependant E/M: 92015 and Material/Hardware Codes (DME)

Monitor Compliance with AuditsMonitor Compliance with Audits

Develop a “Documentation” team

Monthly Assessment– 10 charts/Provider

Report your Results– All staff, residents, students

Acknowledge positive & negative variances– RETRAIN, RETRAIN..

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THANK YOU!THANK YOU! Primary Eyecare Network

– 1.800.444.9230 www.primaryeye.net

– Medicare Compliance Kit Health History Questionnaire Examination Forms E/M Worksheets ICD-9 Codes Interpretation/Report form

– Medicare A-Z Manual– Superbills / Signature on File stickers / Electronic Claims

– HIPAA Compliance Manual– PQRS Card

Compliance Specialists, IncCompliance Specialists, Inc

Billing/Coding/Compliance specialists Audit help/Fee scheduling/Profiling Virtual billing service EyeComply Program

– 10 Chart review/audit– CPT code practice profile– 10 Claims assistance– Builds compliance program – Helps with re-credentialling

Excellence in Optometric Education Excellence in Optometric Education



Introducing ICD-10-CM Introducing ICD-10-CM

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Understanding the Basics & Getting ReadyUnderstanding the Basics & Getting Ready

Differences between ICD-9 & ICD-10 How the ICD-10CM is laid out How to Use the Alphabetic Index How to Use the Tabular List How to Use the Index of injuries How to Use the Table of Drugs & Chemicals How to Understand new Abbreviations How to Use Placeholders How to Use Code Extensions Understand laterality

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The Lilliputians Take Control of the The Lilliputians Take Control of the Healthcare GiantHealthcare Giant

ICD-9 has 13,000 codes ICD-10 has 140,000 Effective date – October 1, 2013 Transition will be difficult as there is little in common

with our current coding paradigms Requires doctors, not staff to do the specific coding Every artery and nerve has been issued a number Number of physicians = 800,000/ 35% own their own

practice (Source Accenture with data from Medical Group management Assoc and AMA)

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Introduction to ICD-10-CMIntroduction to ICD-10-CM Clinical modification of WHO’s ICD-10

– Clinical emphasizes the intent to serve as a tool in classification of morbidity data for indexing, medical records care review, medical & ambulatory care programs, health statistics

Better understand complications Better design robust algorithms Track outcomes

– To describe the “clinical” picture the codes must be more precise

– Far exceeds ICD-9 in number of concepts and codes– Disease classification expanded to include health

related conditions and provides greater specificity

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Improvements Over ICD-9Improvements Over ICD-9 Index MUCH longer

– Ex 28 pterygium, 69 conjunctivitis, 12 astigmatism codes Adds information relevant to ambulatory & MC

encounters Expanded injury codes Combination diagnosis/symptom codes Addition of 6th & 7th characters Incorporates common 4th & 5th digit subclassification Laterality Allows further expansion

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Organization of ICD-10-CMOrganization of ICD-10-CM Alphabetical Index

– Alphabetical list of terms and corresponding codes– Index of Diseases & Injury– Table of Neoplasm– Table of Drugs & Chemicals– Index of External causes of injury

Tabular List– Chronological list of codes– Divided into chapters– Based on body systems

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Tabular List DetailTabular List Detail Chapter 1 Infectious and parasitic diseases Chapter 2 Neoplasms Chapter 3 Diseases of Blood and blood forms Chapter 4 Endocrine, nutritional, metabolic Chapter 5 Mental & behavioral Chapter 6 Nervous system Chapter 7 Eye & adnexa Chapter 8 Ear and mastoid Chapter 9 Circulatory system Chapter 10 Respiratory system Chapter 11 Digestive system

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Tabular List DetailTabular List Detail Chapter 12 Skin & subcutaneous Chapter 13 Musculoskeletal Chapter 14 Gastrointestinal Chapter 15 Pregnancy & childbirth Chapter 16 Conditions of perinatal period Chapter 17 Congenital / Malformations Chapter 18 Signs/Symptoms/abnormal clinical

laboratory findings Chapter 19 Injury, Poisoning, consequences of external

causes Chapter 20 External causes of morbidity Chapter 21 Factors influencing health status & contact

with health services

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Chapter 7: Diseases of Eye/Adnexa DetailChapter 7: Diseases of Eye/Adnexa Detail H00-H05 Eyelid, lacrimal, orbit H10-11 Conjunctiva H15-H22 Sclera, cornea, iris, ciliary body H25-H28 Lens H30-H36 Choroid/retina H40-H42 Glaucoma H43-H44 Vitreous & globe H46-H47 Optic nerve & pathways H49-H52 Ocular muscles, accomodation, refraction H53-H54 Visual disturbances and blindness H55-H57 Other disorders eye & adnexa H59 Intra-operative & post-procedural complications

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Format & StructureFormat & Structure Tabular list contains categories, subcategories & codes Characters may be letter or numbers Categories are 3 characters

– Character 1 is alpha All letter used except U

– Character 2 is numeric– Character 3-7 are alpha or numeric– Use decimal after 3 characters

Subcategories are 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters Laterality specific

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Placeholder CharactersPlaceholder Characters Character “X” used as a placeholder

– Allows for future expansion– Where it exists it must be used to be valid– Ex S05.8x1A

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Placeholder CharactersPlaceholder Characters Code extensions (seventh character) have been added for

injuries and consequences of external causes (S00-T88), to identify the encounter– “A” Initial encounter – receiving active treatment– “D” Subsequent encounter-use after Pt received active treamt– “S” Sequelae-used for complications/conditions arise as result

of injury S only added to injury code, not sequela code Sequela code first, followed by injury code

– Ex: S30 superficial injury of abdomen S30.810, code requires extension to indicate episode of care S30.810A

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77thth Character Character Certain ICD-10-CM categories have 7th digit characters Applicable 7th character is required within the category If code requires 7th character and is not 6 characters, a

placeholder “X” must be used to fill empty character Ex: S05 Injury of eye and orbit, subsequent visit

– S05.00 Looking it up you find “x7th” meaning no 6th character exists but

there is a 7th character mandatory

– S05.00xD

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LateralityLaterality For bilateral sites, final character of code indicates

laterality Unspecified side codes if side not identified in medical

record If no bilateral code provided and condition is bilateral

– Assign separate codes for both left and right Ex:

– H43.811 Vitreous degeneration, right side– H43.812 Vitreous degeneration, left side– H43.813 Vitreous degeneration, bilateral– H43.819 Vitreous degeneration, unspecified

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AbbreviationsAbbreviations NEC “not elsewhere classifiable” NOS “not otherwise specified” “and” represents and / or “code also” instructs two codes may be required [ ] Brackets identify manifestation codes ( ) parenthesis terms are non essential modifiers : Colon incomplete term needing more modifiers

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Excludes CodesExcludes Codes Excludes 1 – pure excludes notes

– Means “NOT CODED HERE”– Indicated code exclude should never be used same time as

code above it Ex congenital vs acquired condition

Exclude 2 – “Not included here”– Condition excluded is not part of the condition represented by

the code

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Etiology / Manifestation ConventionEtiology / Manifestation Convention Some conditions have underlying etiology and multiple

body system manifestations due to the etiology Coding convention requires underlying condition be

sequenced first, followed by manifestation– “use additional code” note exists at etiology codes– “code first” note at the manifestation code

Ex; Dementia in Parkinson’s disease– Code G20 represents etiology– [F02.80 or F02.81] represents manifestation of dementia

With behavioral or without behavioral disturbances

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General Coding GuidelinesGeneral Coding Guidelines

Locating a code in ICD-10-CM– Locate term in Alphabetic Index– Then verify code in the Tabular List– Read and be guided by instructional notations appearing in

both– Essential to use BOTH

Alphabetic index doesn’t always provide FULL code Need Tabular List to assign laterality and 7th character

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Sign & SymptomsSign & Symptoms Codes that describe symptoms and signs, as opposed to

diagnosis Are accepted when a definitive diagnosis has not been

established Chapter 18

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Acute & Chronic ConditionsAcute & Chronic Conditions Acute & Chronic

– Code acute or chronic– If condition is both, code both with acute first

Late Effects (Sequela)– Residual effect after acute phase of illness or injury has

terminated– No time limit– Coding requires 2 codes sequenced in order

Condition first Late effect code second

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External Cause CodesExternal Cause Codes

Chapter 20 Use full range of external cause codes to completely

describe:– the cause, – the intent, – the place of occurrence, – and if applicable the activity of the patient at the time of the

event and– the patient’s status for all injuries and other health conditions

due to an external cause

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Z CodesZ Codes Z codes are analogous to the ICD-9CM “V” codes Most rules of V codes transfer over to the use of Z codes Used to describe routine examinations of many varieties Each with different codes Ex Z00 Encounter for general examination without

complaint, suspected or reported diagnosis Ex Z01 Encounter for other special examination

without complaint, suspected or reported diagnosis

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Steroid Responder Visit Scenario – Old WaySteroid Responder Visit Scenario – Old Way

57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS

CPT 99214 ICD: 365.04

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Steroid Responder Visit Scenario – New WaySteroid Responder Visit Scenario – New Way 57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS CPT 99204 ICD: T38.0x5

– T38.0x1 = accident– T38.0x2 = self harm– T38.0x3 = assault– T38.0x4 = undetermined– T38.0x5 = adverse effect– T38.0x6 = under-dosing

ICD: H40.62 Glaucoma secondary to drugs, left eye– Note states “code first” T36-T50 to identify drug

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Notable & Quotable Notable & Quotable “…Jonathan Swift, where are you today? The

Lilliputians are tying down the healthcare giant with 140,000 threads and calling it a “fundamental advance” MD Tucson AZ

“…this has everything to do with the government forcing more expense, inefficiency and reimbursement delays on already dispirited practitioners…many of my burned out colleagues will gladly follow me into early retirement if this continues” MD Meadville, PA

‘…if this is a small taste of the increasing role of government involvement in healthcare, it is a wonder that any young person has any interest in a career in medicine” SDC, Pittsburgh, PA

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Notable & Quotable Notable & Quotable “…this is government medicine causing the addition of

more ancillary office personnel, more intrusion into the patient’s privacy, more paperwork hours for doctors and one more nail in the coffin of private practice” MD Newport OR

“..every contact will require one of 140,000 codes in order to submit a bill. How much time will medical providers spend choosing the right one, how much will that raise overall medical costs and why is it all worth it? MD Portland OR

“..doctors closing their practices in droves; is there a code for that? MD Niceville FL

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Notable & Quotable Notable & Quotable “…is there an app for that??” OD Los Angeles, CA “..the Mayan Calendar says the world comes to an end

the October before this becomes effective , so don’t worry about any of this..” OD Belize City, Belize

Thank youThank you

Excellence in Optometric EducationExcellence in Optometric Education

Missouri Eye Missouri Eye AssociatesAssociates

McGreal McGreal Educational Educational InstituteInstitute

Missouri Eye Missouri Eye AssociatesAssociates

McGreal McGreal Educational Educational InstituteInstitute

Excellence in Optometric Education

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