Most of the diagnostic technology that has been developed for eye care practices within the last decade has been in the area of “special ophthalmic tests.” These tests have specific rules when performing, recording and coding them. Special ophthalmic tests are contained in a separate section of the Current Procedural Terminology (CPT) coding system, and are described as:1
• Services in which a special evaluation of part of the visual system is made, which go beyond those included under general ophthalmological services or in which special treatment is given.
• Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services.
So, what does that mean? In reality, this means that any test that has a specific definition as a separate and distinct procedure, by virtue of having its own CPT code, is not part of the regular office visit, which is under a general ophthalmologic code (920XX) or an evaluation/management code (992XX).
For example, let’s say that a patient presented with a chief complaint of distorted vision. In the course of your physical exam, you dilated the patient, looked at the macula, and noted some pigmentary changes and drusen. Based upon your physical exam, you order an OCT of the retina. You would bill the office visit with the appropriate CPT code for office visits (920XX or 992XX) and then bill the OCT (92314). Both would be billable because they represent distinct and separate components of the encounter.
Thus, these tests can be ordered and performed by the physician on the same date of service as the office visit, as long as they are performed in accordance with the National Correct
Coding Initiative Edits and meet all requirements specific to your geographic location for medical necessity.
Most audit failures for special ophthalmic procedures are generated by not providing adequate or appropriate medical necessity for performing the test in the medical record. In other words, don’t perform the test simply because you want to do it or are just establishing a baseline.
More on Modifiers
Special ophthalmic codes are composed of two separate and distinct components: professional and technical. If you perform both the technical and professional components in your practice, you don’t separate the code into the individual components, but report the code in its entirety. The two modifiers that separate a code are:
• -26 for Professional Component. Certain procedures are a combination of a physician professional component and a technical component. When the physician component is reported separately, identify this service by adding modifier -26.2
• -TC for Technical Component. When the equipment or technician performs the test, this is identified by adding modifier “TC” to the procedure code identified for the technical component charge.2 Note that the technical component represents both the equipment and the staff person performing the test, so trying to bill for staff time in addition to the test itself is improper and would raise a red flag.
Make Way for MPPR
Other contemporary issues surrounding these tests are being subject to the new CMS rule called the Multiple Procedure Payment Reduction (MPPR). This means that if you perform multiple special ophthalmic procedures on the same day, then full payment is made for the TC service with the highest payment under the Medicare Physician Fee Schedule. Payment is made at 80% for subsequent TC services provided by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day.
As you can see in the example on the opposite page, the CPT code 92025 would be paid in full and the technical component of 92285 would be paid at 80%.
This rule applies to all ophthalmic special procedure tests as well as most ophthalmic ultrasonography tests.3
While many of these special ophthalmic procedures are commonplace in our practices and we’ve been submitting them for what seems like forever, never forget that keeping up on the changes keeps you out of hot water!
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1. CPT 2013 Professional Edition. Chicago: American Medical Association; 2013: 492.
2. CPT 2013 Professional Edition. Chicago: American Medical Association; 2013: Appendix A.
3. MLN Matters. CMS Medicare Learning Network. Multiple procedure payment reduction (MPPR) on the technical component (TC) of diagnostic cardiovascular and ophthalmology procedures. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7848.pdf. Accessed May 20, 2013.
