Coding for Glaucoma & Glaucoma Suspects

transcript

Coding for Glaucoma & Coding for Glaucoma & Glaucoma Suspects Glaucoma Suspects

Glaucoma Risk Factors – Glaucoma Risk Factors – file://localhost/Users/alanhomestead/Documents/My D

ocuments A 2-25-13/Pathology, Education, Pharmaceuticals 8-15-08/Glaucoma/Tests Procedures/Risk/Glaucoma Risk Factors.xls

Office visit, 92 or 99Office visit, 92 or 99

Frequency:Frequency:-As medically indicated -As medically indicated (q 1mo, 3mo, 6mo, (q 1mo, 3mo, 6mo,

12mo)12mo)

-No limit on office visits-No limit on office visits

Special TestsSpecial Tests

Scanning Imaging (GDx, OCT)Scanning Imaging (GDx, OCT)

PachymetryPachymetry

Visual FieldsVisual Fields

Fundus PhotoFundus Photo

Serial TonometrySerial Tonometry

GonioscopyGonioscopy

Extended OphthalmoscopyExtended Ophthalmoscopy

Scanning computerized ophthalmic Scanning computerized ophthalmic diagnostic imaging, diagnostic imaging,

9213292132 Anterior segment Anterior segment

9213392133 Posterior segment, optic nerve Posterior segment, optic nerve

9213492134 Posterior segment, retina Posterior segment, retina

Scanning Imaging Scanning Imaging

Indications, Diagnosis Codes, Indications, Diagnosis Codes, Frequency Frequency Medicare LCDMedicare LCD

Noridian: Noridian: RetiredRetired

CGS: CGS: YesYes

WPS:WPS: YesYes

Novitas:Novitas: YesYes

Palmetto: Palmetto: NoNo

Retired LCD: Retired LCD:

Guidelines not rulesGuidelines not rules

List of ICDs handyList of ICDs handy

No LCD: No LCD:

Clinical judgment allowedClinical judgment allowed88

Diag. code = primary test of medical Diag. code = primary test of medical necessitynecessity

Indications, Diagnosis Codes, Indications, Diagnosis Codes, Frequency Frequency Non-MedicareNon-Medicare

Every plan has own rulesEvery plan has own rules

Clinical judgmentClinical judgment

May follow MedicareMay follow Medicare

Interpretation & ReportInterpretation & Report

YesYes

Interpretation & ReportInterpretation & Report - - MedicareMedicareAddress the findings, relevant clinical Address the findings, relevant clinical

issues, issues,

and comparative data (when and comparative data (when available)available)

Interpretation & ReportInterpretation & ReportSuggestions:Suggestions:

• • SuccinctSuccinct

• • Test reliability (patient compliant, quality of result)Test reliability (patient compliant, quality of result)

• • Results (better, worse or same)Results (better, worse or same)

• • Noteworthy findings Noteworthy findings

• • Diagnosis Diagnosis

Interpretation & ReportInterpretation & ReportSuggestions:Suggestions:

• • Impact on treatment Impact on treatment (no treatment, further test/surgery/consult, (no treatment, further test/surgery/consult,

continue/increase/decrease/stop/add meds)continue/increase/decrease/stop/add meds)

• • Impact on prognosisImpact on prognosis

• • Physician signature Physician signature

Interpretation & Report - LocationInterpretation & Report - LocationNo requirement for specific location of I&RNo requirement for specific location of I&R

I&R can be: I&R can be:

On the test printout/result On the test printout/result

On a separate paperOn a separate paper

In chart notes as discrete entry with other E/M In chart notes as discrete entry with other E/M servicesservices

Interpretation & ReportInterpretation & ReportShould be easily identified as I&R and Should be easily identified as I&R and

not part of exam not part of exam

Should be readily available in case of Should be readily available in case of audit audit

Unilateral / Bilateral Unilateral / Bilateral

CPT: CPT: unilateral or bilateralunilateral or bilateral

Medicare: Medicare: Bilateral since 1/1/11Bilateral since 1/1/11

Non-Medicare: Non-Medicare: No universal rule, may No universal rule, may follow Medicarefollow Medicare

CCI - Correct Coding Initiative CCI - Correct Coding Initiative

Code pairs which are not billed together Code pairs which are not billed together (usually)(usually)

CCICCI

92132 +92132 +9213392133 (-59 ok)(-59 ok)

9213492134 (-59 ok)(-59 ok)

9921199211 (-59 ok)(-59 ok)

CCICCI

92133 +92133 +9213292132 (-59 ok)(-59 ok)

9213492134

9225092250 (-59 ok)(-59 ok)

9921199211 (-59 ok)(-59 ok)

CCICCI

92134 +92134 +9213292132 (-59 ok)(-59 ok)

9213392133

9225092250 (-59 ok)(-59 ok)

9921199211 (-59 ok)(-59 ok)

CCI ExceptionsCCI ExceptionsDifferent anatomical site: R eye & L eye.Different anatomical site: R eye & L eye.

Different patient encounter on same day.Different patient encounter on same day.

Different lesion (disease).Different lesion (disease).

99211: Ok if extra tests ordered - VA, IOP, etc.99211: Ok if extra tests ordered - VA, IOP, etc.

Doctor Order Doctor Order

YesYesPhysician must clearly document in Physician must clearly document in

medical record his intent that the test be medical record his intent that the test be performedperformed

TC, 26 breakout indicates need for Doctor OrderTC, 26 breakout indicates need for Doctor Order

Supervision LevelSupervision Level

GeneralGeneral

Responsible doc must be somewhere on earth, Responsible doc must be somewhere on earth, but does not have to be in officebut does not have to be in office

7651476514Ophthalmic ultrasound, diagnostic; Ophthalmic ultrasound, diagnostic;

corneal pachymetry, unilateral or corneal pachymetry, unilateral or bilateral (determination of corneal bilateral (determination of corneal thickness)thickness)

CGS: CGS: YesYes

WPS:WPS: RetiredRetired

Novitas:Novitas: NoNo

Palmetto: YesPalmetto: Yes

LCD may say:LCD may say:

Once in a lifetime for Glc. Susp.Once in a lifetime for Glc. Susp.

No limit on non-glaucomaNo limit on non-glaucoma

Clinical judgment if no LCDClinical judgment if no LCD

Interpretation & ReportInterpretation & Report

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: unilateral or bilateralunilateral or bilateral

however…however…

33rdrd Party Paying Unilaterally Party Paying Unilaterally (once (once each eye)each eye)

CignaCigna

First ChoiceFirst Choice

Regence – Blue ShieldRegence – Blue Shield

Bill it twice w/ modifier RT & LT, & paid Bill it twice w/ modifier RT & LT, & paid twicetwice

33rdrd Party Paying Bilaterally Party Paying Bilaterally (once for both (once for both eyes)eyes)

MedicareMedicare

Aetna Aetna (1 per life glc & susp)(1 per life glc & susp)

Premera – Blue CrossPremera – Blue Cross

UMP UMP (1 per life glc & susp)(1 per life glc & susp)

PachymetryPachymetryCCI CCI NoneNone

Doctor OrderDoctor OrderYesYes

Supervision LevelSupervision LevelDoes not applyDoes not apply

92081 Limited 92081 Limited (tangent screen, Autoplot, arc perimeter, or (tangent screen, Autoplot, arc perimeter, or

single stimulus level automated test) single stimulus level automated test)

92082 Intermediate 92082 Intermediate (at least 2 isopters on Goldmann perimeter, or (at least 2 isopters on Goldmann perimeter, or

semiquantitative, automated suprathreshold semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test) automatic diagnostic test)

92083 Extended 92083 Extended (Goldmann VF with at least 3 isopters plotted (Goldmann VF with at least 3 isopters plotted

and static determination within central 30 and static determination within central 30 degrees, or quantitative, automated threshold degrees, or quantitative, automated threshold perimetry, Humphrey full threshold 30-2, 24-2, perimetry, Humphrey full threshold 30-2, 24-2, or 30/60-2)or 30/60-2)

Indications, Diagnosis Codes, Frequency Indications, Diagnosis Codes, Frequency Medicare LCDMedicare LCD

CGS: CGS: YesYes

WPS:WPS: YesYes

Indications, Diagnosis Codes, Frequency Indications, Diagnosis Codes, Frequency Non-Medicare Non-Medicare

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: Unilateral or bilateralUnilateral or bilateral

Medicare: Medicare: Bilateral, Payment same whether Bilateral, Payment same whether test one or both eyestest one or both eyes

Non-Medicare: Non-Medicare: No universal rule, may follow No universal rule, may follow MedicareMedicare

CCI CCI 92081 +92081 +

9208292082

9208392083

9921199211 (-59 ok)(-59 ok)

CCI CCI 92082 +92082 +

9208192081

9208392083

9921199211 (-59 ok)(-59 ok)

CCI CCI 92083 +92083 +

9208192081

9208292082

9921199211 (-59 ok)(-59 ok)

Interpretation & ReportInterpretation & ReportYesYes

Supervision LevelSupervision Level GeneralGeneral

9225092250 Fundus photographyFundus photography

(no mention of instrument sophistication)(no mention of instrument sophistication)

(no mention of angle or resolution)(no mention of angle or resolution)

CGS: CGS: YesYes

Palmetto: Palmetto: YesYes

LCD example:LCD example: “ “Fundus photo may be used for Fundus photo may be used for diagnosisdiagnosis

of macular degeneration, retinal of macular degeneration, retinal neoplasms, choroid disturbances, diabetic neoplasms, choroid disturbances, diabetic retinopathy, glaucoma, multiple sclerosis, retinopathy, glaucoma, multiple sclerosis, central nervous system anomalies.” central nervous system anomalies.” (CGS (CGS 2013)2013)

LCD example:LCD example:

“ “to document a disease process, plan to document a disease process, plan its treatment, or follow progress of a its treatment, or follow progress of a disease”disease”

LCD example: LCD example:

“ “not medically necessary simply to document not medically necessary simply to document existence of condition. Photographs may be existence of condition. Photographs may be medically necessary to establish baseline to medically necessary to establish baseline to judge later whether disease is progressive.”judge later whether disease is progressive.”

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: SilentSilent

Medicare: Medicare: Bilateral, Payment same whether one or Bilateral, Payment same whether one or both eyesboth eyes

Non-Medicare: Non-Medicare: No universal rule, may follow No universal rule, may follow MedicareMedicare

CCI CCI 92250 +92250 +

9213392133 (-59 ok)(-59 ok)

9213492134 (-59 ok)(-59 ok)

9921199211 (-59 ok)(-59 ok)

Note: EO is not on CCINote: EO is not on CCI

Fundus PhotoFundus PhotoInterpretation and reportInterpretation and reportYesYes

Supervision LevelSupervision LevelGeneralGeneral

92100 92100 Serial tonometry (separate procedure) Serial tonometry (separate procedure)

with multiple measurements of IOP with multiple measurements of IOP over an extended time period, same over an extended time period, same day (eg,diurnal curve or medical day (eg,diurnal curve or medical treatment of acute elevation of treatment of acute elevation of intraocular pressure) intraocular pressure)

““MultipleMultiple”” = ? = ?

Noridian: Noridian: NoNo

CGS: CGS: NoNo

WPS:WPS: NoNo

Indications, Diagnosis Codes, Indications, Diagnosis Codes, Frequency Frequency Non-Medicare Non-Medicare

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: Silent Silent

Medicare: Medicare: Bilateral, Payment is same Bilateral, Payment is same whether test one or both eyeswhether test one or both eyes

CCI CCI 92100 +92100 +

9921199211 (-59 ok)(-59 ok)

Interpretation & ReportInterpretation & ReportYesYes

Doctor OrderDoctor OrderNoNo

Supervision LevelSupervision LevelConcept does not applyConcept does not apply

92020 Gonioscopy 92020 Gonioscopy (separate (separate procedure)procedure)

CGS: CGS: NoNo

WPS:WPS: NoNo

Indications, Diagnosis Codes, Indications, Diagnosis Codes, Frequency Frequency Non-Medicare Non-Medicare

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: Silent Silent

Medicare: Medicare: Bilateral, Payment is same Bilateral, Payment is same whether test one or both eyeswhether test one or both eyes

CCI CCI 92020 +92020 +

9228592285 (-59 ok, add to 92020)(-59 ok, add to 92020)

9921199211 (-59 ok)(-59 ok)

Interpretation and reportInterpretation and reportNoNo

Ophthalmoscopy, extended, with retinal Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, drawing (eg, for retinal detachment, melanoma); melanoma);

9222922255 initial initial

922292226 6 subsequent subsequent

Extended Extended OphthalmoscopyOphthalmoscopy

CGS: CGS: YesYes

Palmetto: Palmetto: YesYes

LCD example:LCD example:- Initial Initial and periodicand periodic evaluation of evaluation of

serious internal eye disorders. serious internal eye disorders. - Generally covered for neoplasms, Generally covered for neoplasms,

retina disorders, retina disorders, glaucomaglaucoma, trauma, , trauma, vitreous disorders.vitreous disorders.

LCD example:LCD example:

- Stable conditions such as retinopathy in - Stable conditions such as retinopathy in stable diabetic may require only stable diabetic may require only annualannual study while acute intraocular infection study while acute intraocular infection may require may require weeklyweekly studies. studies.

Unilateral / Bilateral Unilateral / Bilateral CPT: CPT: SilentSilent

Medicare: Medicare: Unilateral, Bill separate for each Unilateral, Bill separate for each eye, RT & LT modifiereye, RT & LT modifier

Non-Medicare: Non-Medicare: Typically unilateral Typically unilateral

CCI CCI 92225 +92225 +

9921199211 (-59 ok)(-59 ok)

92226 +92226 +

9921199211 (-59 ok)(-59 ok)

Interpretation and reportInterpretation and reportYesYes

Size & ColorSize & Color

--Palmetto: “minimum size of Palmetto: “minimum size of approximately 4 inches in diameter”approximately 4 inches in diameter”

-CGS: “minimal size of 3-4 inches”-CGS: “minimal size of 3-4 inches”

AMDAMD

file://localhost/Users/alanhomestead/Documents/My Documents B 3-8-13/Adventures 11-3-12/O - S/Presentations/Repository of My PowerPoints/1 Topic Modules/AMD/AMD Aug 13.ppt