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BUSINESS OF RETINA CODING FOR RETINA
Optimizing
Reimbursement in the
Face of Medicare’s
Payment Cuts
Changes in the Medicare Fee Schedule mean physicians must adjust their billing practices to
optimize reimbursements and prevent audits.
BY RIVA LEE ASBELL
T
he Medicare Physician Fee Schedule (MPFS) payment rates for 2015 alter reimbursement for
a number of ophthalmology and retina codes
(Table 1). These cuts do not include the potential
21% cut due from the Sustainable Growth Rate (SGR) that
is scheduled to take place later this year. If history is any
indicator, SGR cuts will be averted, but the MPFS cuts are
here to stay. In order to optimize reimbursement, physicians
will have make sure their coding and compliance enables
generation of all monies that a practice is entitled to and,
simultaneously, avoid paying back monies if audited.
NEW PATIENTS VERSUS ESTABLISHED
PATIENTS
Medicare defines a new patient as one who has not
received any professional face-to-face service for the previous 3 years. If only a diagnostic test has been performed,
and the physician has never seen the patient, then that
patient is considered a new patient. The Centers for
Medicare and Medicaid Services’ (CMS) contract auditors,
such as the Recovery Auditors, audit based on the physician’s NPI (National Provider Identifier) number, and if a
physician has examined a patient in any setting during the
previous 3 years the patient is considered an established
patient.
A number of scenarios can occur whereby a patient is
considered established. Patients examined from a previous practice are still considered established even though
the physician joins a new practice with a different tax ID
number. Similarly, if a physician establishes a solo practice
24 RETINA TODAY MARCH 2015
with a new tax ID number, all patients examined in any setting within the previous 3 years are considered established.
Another scenario is a patient who sees a physician working part-time for your practice and another practice; that
patient is considered established if the physician previously
examined the patient at the other practice. As well, patients
examined in a hospital as a consultation or as a transfer of
care who are subsequently examined in a related office are
considered established.
Three years goes by very fast, and it is important for
whomever is coding to be cognizant that the patient
should be coded as new if there has not been a face-to-face
encounter for 3 years with the examining physician or in the
practice.
To prevent audits related to mistakes with erroneously
coded patients, I suggest several tactics. Your office should
be careful when switching to electronic health record
(EHR) systems. Some EHR systems consider any patient
entered into the system for the first time to be a new
patient. It is important to be sure that established patients
are not coded as new patients. The practice will be
obliged to refund Medicare the difference between the
reimbursement for new patient and established patient
at each coding level. Be sure staff and new associates are
aware that the NPI is the determining factor in whether a
patient is new or not.
EHR CODING OF OFFICE VISITS
Having audited innumerable EHRs of office visits, I can
unequivocally state that there are few, if any, EHR systems
BUSINESS OF RETINA CODING FOR RETINA
TABLE 1. DIFFERENCES IN MPFS REIMBURSEMENT SCHEDULES BETWEEN 2014 AND 2015a
CPT Code
Code Description
MPFS 2014 Fee
MPFS 2015 Fee
Percentage
Schedule Amountb Schedule Amountb Change (+/-)
67028
Intravitreal injection
$113.85
$109.17
-4.1%
67036
PPV
$1071.60
$967.17
-9.7%
67039
PPV/focal endolaser
$1411.20
$1036.34
-26.5%
67040
PPV/PRP endolaser
$1586.08
$1119.34
-29.4%
67041
Vitrectomy with removal of
preretinal cellular membrane
$1483.39
$1237.17
-16.6%
67042
Vitrectomy with removal of
internal limiting membrane
$1696.50
$1237.17
-27.1%
67108
Repair of retinal detachment by
vitrectomy etc.
$1795.97
$1720.59
-4.2%
67113
Complex repair of retinal
detachment
$1954.26
$1869.50
-4.3%
92012
Office visit, eye code,
established patient, intermediate
$92.52
$91.30
-1.3%
99204
Office visit, E/M code, new
patient, level 4
$176.49
$175.99
-.02%
92235
Fluorescein angiography
$117.71
$118.31
+.05%
a
Reimbursement amounts differ according to area of practice. To find your specific reimbursement rate for 2015, visit your
local Medicare Administrative Contractor’s website.
b Medicare Physician Fee Schedule (MPFS) amounts for 2015 are those approved by Congress for January 1, 2015 through
March 31, 2015.
Abbreviations: MPFS, Medicare Physician Fee Schedule; PPV, pars plana vitrectomy; PRP, panretinal photocoagulation;
E/M, evaluation and management
that accurately code for Medicare encounters, particularly
because the chart documentation rarely supports the
level of the code selected by the EHR. For example, a
template may have the correct number of examination
elements to be documented, but the method of documentation is typically not as prescribed by CMS. The final
result of all of this is that physicians often undercode
from fear of being audited or having to refund monies
because the chart documentation does not support the
code. Such EHR system inadequacies may be due, in part,
to basic programmers’ lack of knowledge about Medicare
compliance and guidelines. It is crucial that physicians
make an effort to obtain proper coding training for themselves and their staffs. Table 2 offers tips to make sure you
stay in the know about guidelines and EHRs.
SURGERY ISSUES
The most perplexing surgery issues concerning
payment involve coding for procedures performed in the
global period of another procedure. A patient may present with symptoms unrelated to the medical condition
TABLE 2. OPTIMIZATION TIPS
• Have your EHR templates professionally critiqued.
• Study the 1997 E/M Guidelines.
• Free courses (webinars/seminars) are available in
various formats from your Medicare Administrative
Contractor (MAC).
• Be sure to sign up for your MAC’s e-mail lists.
Remember, the physician is responsible for adhering
to the guidelines and Local Coverage Determinations
(LCDs).
while still in the global period. However, the surgery may
require the same CPT codes that were used in the original
Medicare claim. These scenarios usually involve procedures
that require the same modality of treatment and, although
different, are positioned in the same general anatomic area.
For example, if a patient presents with new retinal breaks
during the global period of external laser treatment (67145)
MARCH 2015 RETINA TODAY 25
BUSINESS OF RETINA CODING FOR RETINA
TABLE 3. THE THREE C’S
• Clinical Diagnosis
• Tip: Be sure to use the symptoms for which the
test was ordered if there is no final diagnosis.
• Comparative Data
• Tip: If it is a new patient, there may not be any
comparative data, so just note “Not Applicable.”
• Clinical Management
• Tip: Describe briefly how the test is being used—
this is mandatory for documentation, even if it is
a statement such as “No treatment indicated at
this time.”
for treatment of retinal breaks, then the treatment of the
new breaks may be coded for by appending modifier 79,
which indicates that the current procedure is unrelated
to the original procedure.
It is imperative that physicians master the use of
modifiers 58, 78, 79, and 59. (See “Coding for Surgical
Procedures in the Global Period” in the September 2014
issue of Retina Today for more on this topic.) Choose
your surgical codes carefully. For example, when performing a lensectomy in conjunction with a vitrectomy
procedure, CPT instructions mandate use of code 66850
(Removal of lens material; phacoemulsification). Using
CPT code 66852 (Removal of lens material; pars plana
approach, with or without vitrectomy), which is bundled
with the vitrectomy codes, will result in that code being
denied.
Another example is coding for repair of a recurrent
retinal detachment in the global period of a previous
repair of the retinal detachment using the same technique. In this case, because the second procedure is considered related to the first, the same CPT code (usually
67108 [Repair of retinal detachment with vitrectomy])
plus modifier 78 should be used rather than CPT code
67112 (Repair of retinal detachment by scleral buckling
or vitrectomy on patient having previous ipsilateral retinal detachment repairs) plus modifier 78 . Both are correct, but using the code 67108 with modifier 78 results in
higher reimbursement.
Peripheral iridectomy (66625) is not bundled with the
retinal detachment repair codes and may be coded if
medically necessary.
In order to prevent audits and subsequent paybacks,
do not use modifier 25 to engender payment for an
office visit when coding intravitreal injections or other
surgeries classified as minor (zero day global period for
Medicare) unless there is a separate and significant condition that is being addressed.
26 RETINA TODAY MARCH 2015
Also, you should avoid excessive use of modifier 59,
especially for treating the same condition by the same
modality in contiguous structures. The National Correct
Coding Initiative (NCCI) specifically states that “two
procedures/surgeries cannot be reported together if
performed at the same anatomic site and same patient
encounter. The provider cannot use modifier 59 for such
an edit based on the two codes being different procedures/surgeries. … The definition of different anatomic
sites includes different organs or different lesions in the
same organ. However, it does not include treatment of
contiguous structures of the same organ. … Treatment
of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site.” Be sure you
and your billing staff are up-to-date on Medicare’s latest
modifier 59 regulations. (See “New Modifier 59 Coding
Revisions” in the November/December 2014 issue of
Retina Today for more on this topic.)
OPHTHALMIC DIAGNOSTIC TEST ISSUES
Retina practices tend to use diagnostic testing more
frequently than most other ophthalmic subspecialties.
For instance, the utilization rate of extended ophthalmoscopy by a retina specialist per 100 beneficiaries is
likely to be significantly higher than that of colleagues in
cataract and refractive surgery or glaucoma practice—a
fact that is likely to trigger a utilization audit.
CPT 2015 requires a written interpretation and report
for all diagnostic ophthalmic tests except for gonioscopy and ophthalmodynamometry. The report should
include the Three C’s found in Table 3. It is imperative
to document the interpretation and report separately
from the main body of the chart documentation and to
ensure it is properly labeled. (See “Chart Documentation
for Ophthalmic Diagnostic Tests” in the May/June 2014
issue of Retina Today for more on this topic.)
To avoid audits, make sure the chart documentation
contains an order for each test and a signature. Also,
make sure that images of any diagnostic tests, as well
as an interpretation and report, are included for each
test. For example, if you intend to bill fundus photographs and fluorescein angiography separately in order
to receive separate payment for each, then each test
requires an individual report. n
Riva Lee Asbell is the principal of Riva Lee
Asbell Associates, an ophthalmic reimbursement consulting firm located in Fort Lauderdale,
Florida. Ms. Asbell may be reached at
rivalee@rivaleeasbell.com.
CPT codes copyrighted 2014 American
Medical Association.