Table Rock Regional Roundup Part 1: Costly Coding Errors and Lessons Learned from Real Life Audits ,Friday, September 23, 2016
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Table Rock Regional Roundup
Part 1: Costly Coding Errors
and Lessons Learned from
Real Life Audits
,Friday, September 23, 2016
Financial Disclosure
•Sue Vicchrilli, COT, OCS
o Has no financial interests or
relationships to disclose.
Topics
• #1 Rule of Coding
• Local Coverage Determinations Unique
to Novitas and WPS
• What’s on Fire by specialty
• #2 Rule of Coding
#1 Rule of Coding
#1 Rule of Coding
• Do not take the rule or perceived rule of
one payer and apply it to all payers.
Local Coverage Determinations
Local Coverage Determinations
• The rules and regulations for which you
are held accountable in an audit.
o Must follow the LCD in place at the time of
the test or surgery
o Signing up for free listserv, you’ll receive
weekly communication about any changes
Novitas: Arkansas and Oklahoma
• Benign skin lesions
• Blepharoplasty
• Cataract including complex cataract
• Co-management of surgical procedures
• Glaucoma with aqueous drainage device
• Lacrimal punctum plugs
• Scanning computerized ophthalmic diagnostic imaging
Novitas: Arkansas and Oklahoma
• The fiscal year (FY) 2015 Medicare FFS program
improper payment rate:
o 12.1 percent
o representing $43.3 billion in improper payments
Novitas: Arkansas and Oklahoma
• CERT
• E/M services coded based on time
o Physician face-to-face time documented.
o Must have elements of exam medically
necessary to perform
o Not just time spent counseling patient
Novitas: Arkansas and Oklahoma
• Probes
o No active probes for ophthalmology at this
time
WPS: Kansas and Missouri
• Benign skin lesions
• Blepharoplasty
• Botulinum toxin
• Category III codes
• Low vision services
• Scanning computerized ophthalmic diagnostic imaging
• Visual fields
WPS: Kansas and Missouri
• Currently under scrutiny:
• Bleph/ptosis repair
o Separate visual fields of taped and
untapped lids and brow areas need to be
submitted to support the medical necessity
of the services billed.
o Physician interpretation must also be
included with the visual fields.
WPS: Kansas and Missouri
• Currently under scrutiny:
• Photos for brow ptosis repair:
o Photographs should document medical
necessity for brow ptosis repair. Frontal
photographs are necessary.
WPS: Kansas and Missouri
• Currently under scrutiny:
• For blepharoplasty repair:
o Frontal photos are needed to demonstrate
redundant skin on the upper eyelids.
WPS: Kansas and Missouri
• Comparative Billing Reports For Service Specific Probes
o Cardiology
o Emergency medicine
CERT Review Results
• Can be tracked online
o To obtain the results of your Comprehensive Error
Rate Testing (CERT) review(s) visit your payer
website for specific instructions.
What’s on Fire
Cataract/Anterior Segment
A-scan
• 76519 or 92136
• Must be correctly linked to ICD-10 codes
• Example:
o Exam can be linked to right, left of bilateral cataract
o Ascan linked to surgical eye
o Surgery in right eye. ICD-10 ends in a 1
Cataract Surgery
• What are the documentation requirements that apply to
all payers?
• What is unique to your MAC?
• What can patients be billed out-of-pocket?
What have the probes taught us?
• Probe revealed:
o No evidence of patient’s Best Corrected
Snellen Visual Acuity (BCVA) present in the
record.
o No evidence of patient reported impairment
of visual function resulting in restriction of
activities of daily living.
What have the probes taught us?
• Probe revealed:
o A signed operative note/report is not present.
o No documentation indicating the patient desires surgical
correction, has received explanation of
risks/benefits/alternatives and expected outcome will
significantly improve visual and functional status.
Secondary Cataracts
• What are the documentation requirements that
apply to all payers?
• What is unique to your MAC?
• Payable inside the global period
o What modifier(s)?
Retina
Description/Global Period Change
∆ 67227 Destruction of extensive or
progressive retinopathy (eg, diabetic
retinopathy), one or more sessions
cryotherapy, diathermy
o 10-day global period
o Confirm with commercial payerso 2015 Office $624 / Facility $583
o 2016 Office $296 / Facility $263
Description/Global Period Change
∆ 67228 Treatment of extensive or
progressive retinopathy (eg, diabetic
retinopathy), one or more sessions
photocoagulation
o 10-day global period (Actually 12 days)
o Confirm with commercial payerso 2015 Office $1,021 / Facility $967
o 2016 Office $348 / Facility $314
Palmetto probe revelations
• Injecting Avastin, billing for Lucentis
• Avoiding the 28-day rule by alternating
drugs.
Coding for Avastin
• J3490, J3590, J7999, J9035 and C9257
o Depending on the payer and the location
o What to do with cross-over claims for
secondary payers who don’t recognize the
HCPCS code?
Modifier -25
• While medically necessary, if the
established patient exam is performed
solely to confirm the need for the minor
surgical procedure, then the exam is not
separately billable.
What the audits have taught us
• Request is for consecutive charts, not a
single date of service.
Testing Services Monitored
• Testing services require
o Written order for delegated tests
o Standing order/screening = paid by patient
o Frequency
o Combination tests
o Unbundling
o Supervision
Testing Services Monitored
• Independent photographer
• Fundus photo with each intravitreal injection
Glaucoma
Payment Issue with 65855 ALT/SLT
• Bilateral performance.
• 65855 -50 and a 1 in the unit field.
• New CMS indicator of 2 instead of 1 for
bilateral surgery.
Payment Issue with 65855
• Good news!
o Fix effective July 1
o Reprocess your claims for the additional
50% payment
$140 if office based
$123 if facility based
iStent
• 0191T iStent
o +0376T each additional device
Under payment review
Cornea
Global Period Change
• CPT codes 65778 AMT without sutures,
and 65779 sutured
o 0-day global period for Medicare Part B and
MA plans
Was 10-day
o Confirm any change with commercial
payers
Site of Service Payment Difference
Office ASC
$1,411 $72
Includes supply
of PROKERA
ASC absorbs cost
of PROKERA
Oculofacial
New: Unique Taxonomy Code
• New taxonomy code unique to specialty.
• Component of ophthalmology taxonomy
• Continue to follow established patient of
the practice rules.
New: Claim Denials
• Payers may deny lid CPT codes when
appended with modifiers -RT/-LT.
• They require HCPCS modifiers E1-E4.
• Be sure to link to correct ICD-10 code.
HCPCS vs. ICD-10 Liderality
HCPCS Modifier ICD-10 Code
E1 Left upper Ends in 4
E2 Left lower Ends in 5
E3 Right upper Ends in 1
E4 Right lower Ends in 2
CCI Edits effective April 1, 2009
Column 1 Column 2
67901, 67902 and 67904 15822 and 15823
67903, 67906 and 67908 15822
15823 67903, 67906 and 67908
New: Bleph/Ptosis MLN MM9658
• A blepharoplasty cannot be billed to Medicare
and the beneficiary cannot be separately
charged for a cosmetic procedure regardless
of the amount of upper eyelid skin that is
removed on a patient receiving a
blepharoptosis repair because removal of any
amount of upper eyelid skin is part of the
blepharoptosis repair. Plus more . . .
RA and SMRC
• If you’ve passed former audits, should
not be subject to more!
#2 Rule of Coding
#2 Rule of Coding
• Don’t guess
o www.aao.org/coding
o Essential Topics book
o Coding Coach
o Complete Guide to Retina
o Specialty modules
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