EXTENDED OPHTHALMOSCOPY
This remains one of the most heavily audited codes in ophthalmology.
Tips:
- It is a unilateral test, therefore there must be medical necessity–either clinical findings or symptoms for each side when performing direct ophthalmoscopy.
- An anatomically specific drawing is required–using a few colors is preferred. The drawing must be labeled. Recommended size is 3+ inch diameter. EMR sketches rarely qualify
- A separate Interpretation & Report must be included (see www.RivaLeeAsbell.com for article "The Three C's: Interpretation and Report Requirements for Diagnostic Tests".
- For level 4 and 5 E/M visits you must document optic nerve and posterior segment separately and then continue to Extended Ophthalmoscopy.
- Be sure to follow your Medicare Administrative Contractor's local coverage policy (LCD) even if it is retired.
BILLING OFFICE VISITS & INTRAVITREAL INJECTIONS
The 25 modifier has been overused with intravitreal injections and is under OIG (Office of the Inspector General) investigation.
Definition of Modifier 25: (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service). It is used to engender payment for both the office visit and minor surgery procedure (global period of 0 or 10 days) when performed on the same day.
Tips:
- DO NOT USE MODIFIER 25 on the office visit when the injection has been previously scheduled.
- DO NOT USE MODIFIER 25 if the chart documentation reflects the purpose of the examination is the injection itself.
- DO NOT USE MODIFIER 25 if you are following a protocol or participating in a clinical trial that specifies injections at given intervals.
- Remember, just because you examine the patient does not mean you are entitled to bill for the office visit. For Medicare usually 20 percent of the global fee is for preoperative evaluation.
- Make sure your chart documentation clearly states that the OCT will be evaluated and the decision for surgery will be made at a later date. Avoid cookie cutter documentation– another focus of the OIG this year.
PLACE OF SERVICE ERRORS
One of the primary foci of RAC audits is Place of Service (POS) errors. Here are some surprises.
Tips:
- If you examine an inpatient in your office, the POS remains inpatient hospital, not office.
- When performing diagnostic tests on an inpatient the POS remains inpatient hospital.
- Do not code outpatient visit codes (E/M or Eye Codes) for examination of a patient with inpatient status.
MODIFIER 24 ERRORS
Another focus of OIG audits is using modifier 24 in order to engender payment for an office visit in the global period.
Definition of Modifier 24: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure…
Tips:
- It is the office visit, not surgical services that requires a return to the OR, that cannot be billed.
- Clinical Example (Nonqualifying = Related)
Panretinal photocoagulation (PRP) was performed in the right eye for Proliferative Diabetic Retinopathy (PDR). Patient presents with new floaters and vitreous hemorrhage in the right eye. If the reason for the encounter is related to the disease process you should not bill for the office visit.
- Clinical Example (Qualifying = Unrelated) PRP had been performed on the left eye and patient presents with a vitreous hemorrhage in the right eye. Patient has bilateral PDR; however, the right eye had never been treated nor was a vitreous hemorrhage previously diagnosed. An office encounter can be billed for new problems in the contralateral eye that present for the first time.
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