News from the AOA's Blog

Edited by Chuck Brownlow, O.D., Medical Records consultant

Question: I’m currently being audited by a very large national insurance company. They say my records do not support the codes that I’ve reported. What can I do?

Answer: I don’t mean to be blunt, but if the insurer’s auditor is correct and your records don’t support the codes you’ve billed, chances are you will be paying money back to the insurer. This is becoming more common in health care, partially because all health care providers are much more interested in providing care than in learning the rules for billing for that care. Most providers have done an excellent job in providing patient care and in keeping up to date with changes in diagnosis and management of patients’ conditions. Unfortunately, many have not done a very good job of learning the rules for reporting that care to insurers, including the accurate choice of codes for their services. Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., Medical Records consultant

Question: What’s this about a $505 fee that we have to pay in order to continue to supply post-op glasses to our cataract patients? 

Answer: Several months ago, the Centers for Medicare & Medicaid Services (CMS) announced that all Medicare providers and suppliers would have to pay a fee when they enroll or re-enroll. The AOA helped obtain an exemption from Congress for physicians, but the CMS decided not to extend the exemption to physicians who enroll as suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). All DMEPOS suppliers are required to re-enroll periodically and to pay a re-enrollment fee, currently $505, when their re-enrollment date comes around. No action is necessary until practitioners are informed by the National Supplier Clearinghouse that it’s time for them to re-enroll. They can continue to provide post-op glasses for cataract patients in the meantime. Our best information suggests that re-enrollment will be required every three years.  Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., Medical Records consultant

The debate rages on with respect to which set of office visit codes is better for eye care: the 99000 series Evaluation & Management Services or the 92000 General Ophthalmological Services.  All office visit codes are listed in and defined by the American Medical Association (AMA) publication Current Procedural Terminology© (CPT), the only national authority regarding procedure codes and their definitions.  Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., Medical Records consultant

The first four months of 2011 have provided challenges for all doctors who commonly provide retinal imaging services for their patients.

Some insurers and several Medicare carriers have published their guidelines for coverage of the new codes; 92132, 92133, and 92134; though many insurers have not.

As I’m writing this, the Centers for Medicare & Medicaid Services (CMS) have not released a National Coverage Determination (NCD) for the codes. Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., Medical Records consultant

Unlike most health care providers in the United States, a clear majority of optometrists have a hand in their own destiny, at least with respect to insurance contracting. In most of medicine, the doctors have become employees of large clinics, hospitals, and health care centers, and decisions regarding panel participation, acceptance or rejection of insurance contracts, participation in governmental health plans, fee schedules, and even their own salaries are determined by the managers of their facilities.

In optometry, a common scenario is that clinics are owned by some or all of the doctors within the clinic, with the doctors serving as managers. Among the management decisions made by the doctors are the clinic’s fee schedule, panel participation, and acceptance or rejection of vision and health plan contracts.  Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., AOA Coding and Medical Records consultant

The darker side

AOA members and their staffs have sent hundreds of questions and comments to us through askthecodingexperts@aoa.org over the past three months, many of which focused on the significant reductions in Medicare reimbursements for retinal imaging. As we all know by now, a favorite old Current Procedural Terminology© (CPT) code, 92135, has been replaced by two new codes, 92133 and 92134. The change in codes would not have attracted much attention and may even have been appreciated if not for the additional news we received about the new codes; CPT classifies them each “unilateral or bilateral,” essentially meaning that if the code is used alone, without modifiers, the practitioner is paid the same, whether he or she completed the imaging on one or both eyes.  The third bit of news was that Medicare established relative values for the new codes that were nearly identical to the 2010 relative values for the old unilateral code, 92135. That change effectively set the value of each of the new services at half of the value of 92135. Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Myth #1—“I can’t set my fees any higher than Medicare’s ‘Allowed Charges.’”

Response—Not True! I have no idea how this one ever got started, but it is in full opposition to the logic of insurance programs. 

Insurers, including Medicare, expect and even require providers to report their usual charges on a claim, not what they expect the insurer to pay. 

That means providers are to report fees that they believe accurately reflect the value of their own services.  Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

You may remember that things looked pretty bleak for Medicare providers back in November. Governmental budget woes, especially Medicare budget woes, coupled with Medicare’s formula for coming up with fee schedules each year, had providers in an uproar. Following a pattern that has continued for the past several years, Medicare had applied the formula for establishing reimbursements, the new fee schedule was exposed in late autumn, the cuts were very large, all health care professions protested the cuts to Congress, and Congress acted in December to save the day… sort of.

Congress did roll back the cuts that Medicare had proposed. On first reading, that would have meant that the “allowed charges,” Medicare’s name for reimbursements, would have been identical to those of the second half of 2010. This couldn’t happen though because Medicare’s relative values for quite a few of the covered services had been adjusted upward for 2011. Thus, if things would have been permitted to proceed directly from the 2010 fee schedule to 2011, allowed charges on quite a few services would have actually gone up. Those rises would have meant an end to Medicare’s quest for neutral budget impact. One more adjustment was necessary. Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Three new codes will replace 92135. 2011 Current Procedural Terminology (CPT©, American Medical Association) includes one very significant change affecting eye care. 92135. “Scanning computerized ophthalmic diagnostic imaging, posterior segment, (e.g., scanning laser) with interpretation and report, unilateral,” has been eliminated.

In turn, CPT created three new codes for imaging, one for reporting anterior segment imaging and two for posterior segment imaging. The following codes and definitions will be in effect Jan. 1, 2011:

• 92132 — Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (replaces the 2010 CPT Category III code, 0187T)
• 92133 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
• 92134 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

Read the rest of this entry ?

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Optometrists have been doing procedures for decades that are that are listed in the Surgery section of Current Procedural Terminology© (CPT). Among those services are the removal of foreign bodies from the eye and adnexa, correction of trichiasis, closure of punctum by plug, etc. As is true of all CPT codes, they must be used only when the service matches the definition in CPT, and they must be used according to the rules established by and recorded in CPT.

As is true with each section of CPT, the Surgery section begins with “Surgery Guidelines.” Within the Guidelines section, one can find the “CPT Surgical Package Definition.” It reads, “The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure by procedure basis, a variety of services. In defining the specific services ‘included’ in a given CPT surgical code, the following services are always included (emphasis added) in addition to the operation per se…”  Read the rest of this entry ?