Wow. 2009 is nearly over—and what a year it has been. As I write this, health care reform bills have been passed by the House and have moved to the floor in the Senate. The Centers for Medicare & Medicaid Services have proposed some significant cuts to Medicare spending in 2010. Congress is in the process of permanently fixing the physician payment formula that causes great consternation each fall. And, I didn’t even mention the ups and downs with the economy…

There has, however, been one resounding message that I have heard from all of you during the course of the year, both at programs where I lecture and in letters responding to this column: Those O.D.s who have incorporated medical eye care into their practices and who have learned how to appropriately code and bill for their services have fared much, much better than practices that are primarily dependent on retail sales.

One great thing about the practice of optometry is that we can have our cake and eat it, too. Developing a great practice built upon professional services is not mutually exclusive of providing a great retail experience for patients—we can excel at both!

With that in mind, I’d like to share a few questions sent in by readers during the past year:

 

In the article “Common Codes for the Retina” (October 2009), it said, “92250 and 92135 are considered mutually exclusive under the National Correct Code Initiative (NCCI), so don’t bill for these for the same patient on the same day.” However, the rep from [one manufacturer of spectral domain ocular coherence tomographers] said you can, if you bill one of the procedures using the 92499 code. What do you say about that? Just rep talk or true?

Unfortunately, it’s just rep talk. The CPT clearly states that a physician is obligated to use the CPT code that most accurately describes the service provided. Since there is a specific code for both scanning laser diagnostic imaging (92135) and fundus photography (92250), using 92499 (unlisted ophthalmic procedure) to describe either of those services would be highly inappropriate.

 

I heard from a colleague that I can bill both the vision carrier and the medical carrier for the same visit if the patient has both a medical diagnosis and a vision diagnosis. Is that true?

Unfortunately, it’s not. The nature of the visit, as well as the party responsible for payment, is determined by a combination of the nature of the chief complaint and contractual obligations of each respective carrier. For example, I have had many individuals try and convince me (unsuccessfully, by the way) that if a patient presents with vision coverage and has diabetes, they can bill the vision carrier for the refraction portion of the examination only and the medical carrier for the rest of the examination because the reimbursement is higher. This is a clear violation of both procedure and policy.

If your provider agreement  with the vision carrier stipulates that you perform a 92004/92014/ 92002/92012 and a 92015 with the patient, then you must perform those services and bill to the vision carrier accordingly. Any subsequent services required by medical necessity—photos, fields, etc.—can be ordered and performed by the physician and billed to the medical carrier.

Keep in mind that the core fundamental concepts of medical necessity and chief complaint play a significant role in what you do and how you do it. (See “Two Key Terms for Compliance,” June 2009, for more detail regarding these concepts.)

 

I wish you all of the best. Happy Holidays and Happy New Year! Next year will be an exciting one to be sure. Buckle up and read us monthly to keep up with all of the changes coming our way!

Please send your comments to CodingAbstract@gmail.com.