MANAGED CARE UPDATE
  Also see: MEDICARE Q&A

Should Narrow Angles
Equal Narrow Payments?

by Randolph Brooks, O.D. 

We've fought for and won the right to treat glaucoma patients, but as primary eye-care providers, we still face two challenges when it comes to glaucoma. The first is to keep abreast of the latest research, therapeutics and technology so we can provide the most appropriate care for our patients. Fortunately, we have several resources available.

The second challenge: getting paid for the care of these patients. This is even more confusing, as the rules are changing. We must balance the requirements of Medicare and managed-care plans with what we feel is the most appropriate care for our patients. Even the best clinicians may find this juggling act difficult.

We periodically receive letters and e-mails from doctors who want to know how to use some of the codes for diagnosing and treating glaucoma. Here's a sampling of them, and my answers.

Dear Dr. Brooks: I saw a new patient with very narrow angles who had lost most of her peripheral field out of her right eye. We performed a comprehensive exam, gonioscopy and threshold visual field tests in both eyes. We then billed Medicare with the following diagnosis and procedure codes: 365.02 (anatomical narrow angle), 368.40 (visual field defect, unspecific), 92004 (comprehensive exam, new patient), 92015 (refraction; we know this a non-covered service), and 92020 (gonioscopy). For the visual field exam, we billed 92083-RT and 92083-LT.

When we received the Medicare payment and remittance notice, we only received payment for the exam and for the visual fields as a bilateral service. Our carrier did not pay for the gonioscopy, stating that "this procedure/service is not paid separately."

Did I use a wrong procedure code for gonioscopy? I never thought of gonioscopy as a normal part of a comprehensive exam, but as special testing when needed.

Also, how should I bill visual field tests? Do I bill them as a bilateral test? It doesn't make sense that I get the same payment for a bilateral or unilateral test. Shouldn't I get paid by how much I do, especially since a bilateral threshold visual field takes twice as much time?—Grace Wong, O.D., Los Angeles.

Dear Dr. Wong: You raise several important questions. Your ICD-9 diagnosis codes should be more specific to your patient's diagnosis. The proper diagnosis code would most likely be 365.20 (primary angle closure glaucoma, unspecified). The diagnosis code that you used, 365.02, refers more to a borderline glaucoma suspect. Also, the 368.40 should probably be 368.43 (sector or arcuate defects). Remember to always use the most appropriate and the most specific diagnosis possible. Certain diagnosis codes must be carried out to the fifth digit. Consult your ICD-9 code book for specific examples.

As part of its Correct Coding Initiative, the Health Care Financing Administration (HCFA) bundled gonioscopy into the 92000 series eye exam codes. It also did so with the codes for serial tonometry (92100) and sensory motor evaluation (92060). HCFA considered bundling these procedures into the 99000 level evaluation and management (E/M) codes as well. Some carriers, in fact, did bundle these codes into the E/M codes.

However, HCFA recently reversed its decisions and unbundled these codes as of July 1. It also has tabled bundling these procedures into the E/M codes. Some more good news: This unbundling is retroactive to January 1, 1998, the date when HCFA first bundled these codes together.

HCFA has told local Medicare carriers to review claims from this period. Since your carrier didn't pay for the gonioscopy separately, it should reprocess your claim. The same holds true for serial tonometry and sensory motor evaluation.

You'll probably need to resubmit these claims. However, before you rush to do so, make sure your carrier has installed updated software that reflects the unbundling. Otherwise, the carrier's computer system may automatically reject your claim as a duplicate claim.

As for the visual fields, Medicare, managed-care plans and other third-party plans consider visual fields as a bilateral test. There's both a technical and professional component. So, you must bill any of the visual field codes (92081-92083) as one unit rather than separately for each eye.

You're right to feel that you should be paid twice as much for a bilateral threshold field. This fee actually does reflect a bilateral test and interpretation. If you perform the test on one eye, you must use a  -52 reduced services modifier, and your reimbursement will be less.

Although you didn't ask about serial tonometry (92100), we should discuss this code, too. Serial tonometry generally refers to the use of four or more pressure measurements in the same day. The test is indicated when you suspect diurnal pressure variations or in patients who have chronic or acute narrow-angle glaucoma.

Many O.D.s mistakenly bill for serial tonometry when they perform non-contact tonometry at the beginning of the exam and Goldmann applanation tonometry at the end. You can be sure commercial carriers and Medicare are carefully scrutinizing the use of this code.

Dear Dr. Brooks: What makes extended ophthalmoscopy different from a standard dilated fundus exam? Also, how do I justify extended ophthalmoscopy to Medicare?—Elisabeth J. Binnig, O.D.

Dear Dr. Binnig: Optometrists and ophthalmologists often misuse this code. To bill for extended ophthalmoscopy (92225, new, and 92226, subsequent) you must have a drawing and report. Some Medicare carriers require detailed 8 x 11-inch fundus drawings in full color, while others allow sketches with less detail. Rules vary among carriers, so check with yours. Also, ask the managed-care plans in which you participate for their guidelines.

Another requirement for extended ophthalmoscopy: The test must be medically necessary. Some carriers produce a list of diagnoses they consider acceptable for performing extended ophthalmoscopy.

Overuse of the extended ophthalmoscopy codes has been a problem, so now carriers are carefully scrutinizing claims. Some are conducting audits. Make sure this test is medically necessary for your patient, and follow the documentation requirements. If you're not sure, ask your local Medicare carrier or managed-care plans, or check with your state optometric association.

You should bill for extended ophthalmoscopy as a monocular code. If you perform the test in one eye only, you bill one unit, right or left. If you examine both eyes you bill two units with a -50 modifier.

Now that we can treat glaucoma patients, we must expect to be held to the same standard care as ophthalmologists and other doctors. We must follow appropriate treatment guidelines and comply with the rules for getting reimbursed. The ocular health of these patients as well as the health of your practice depends on this correct treatment and billing.

Send questions to Dr. Brooks c/o Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089; or e-mail them to reviewofoptometry@jobson.com.

MEDICARE Q&A

Different Rules for Testing at Different Offices?

by Jeffrey S. Eisenberg

I wanted to run a visual field test on a patient with moderately large cupping changes. The patient was in a wheelchair and could not use our field unit, so a colleague allowed me to borrow his wheelchair-accessible unit. I ran the field on the colleague's unit at his office. How should I bill this to Medicare?—Jeffrey W. Lozen, O.D., Sault Ste. Marie, Mich.

Heather Loveland, a Medicare consultant and an insurance consultant to the Tennessee Optometric Association, suggests these two alternatives:

• Bill the appropriate visual field exam code (92081, 92082 or 92083) under your own provider number. In block 32 of the HCFA-1500 form, indicate the address where you performed the test. Your carrier shouldn't require an explanation. If it does reject the claim, you can appeal.

• If the other doctor ran the test, he could bill Medicare with the -TC modifier, indicating the technical component. You, then bill with the -26 modifier for the professional component, indicating that you reviewed the test results.

One precaution, however: You can't pay your colleague for use of his equipment and then bill Medicare. This would violate its purchased diagnostic test guidelines, Ms. Loveland says. However, the other doctor could bill Medicare and then reimburse you.

Send your Medicare questions to Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089; or e-mail them to reviewofoptometry@jobson.com.

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