2012 Medicare Fee Schedule
Congress acted in February to extend the temporary ‘fix’ of Medicare’s Fee Schedule through December 2012.  You will recall that Medicare proposed a 27% cut in physicians fees for 2012, which Congress delayed to March 1. For all of 2012, Medicare’s fees for eye care are nearly identical to 2011, with very small increases (less than 5%) in some of the office visit and eye related procedures.  Expect the craziness to reappear in late 2012.

Medicare Audits
Warning!  Many health care providers continue to ignore the national rules for record keeping and coding; behavior that will have unhappy consequences during audits by Medicare and other insurers.

So far, we know of no Wisconsin ODs who have been involved in the latest round of Medicare audits, but based on experience in surrounding states, we know audits are coming.  Medicare is using independent contractors for the audits, with the auditors’ payments calculated as a percentage of dollars represented in the billing errors they discover. This is an excellent time for every WOA member to review protocols for medical record keeping, including emphasis on accurate recording of the patient’s reason for visit, and accurate choices of codes based on the content of the record, compared with the Current Procedural Terminology (CPT @ American Medical Association) definitions and the 1997 Documentation Guidelines, for the 99000 series, Evaluation and Management Services.

Special Audit Concerns for Electronic Health Records
The Office of Inspector General (OIG), Medicare’s enforcement arm, has raised a red flag for Medicare auditors, specifically related to electronic records.  Any good thing can be misused.  Anything that simplifies or speeds an oft-repeated task will be welcomed by many, including health care providers. Each time a convenience is added, risks arrive, too.  Most current EHR programs permit doctors and staff to pull data from a previous visit into the new record, speeding the entry of data and avoiding duplication of effort.  Medicare is concerned that some of the data being ‘cloned’, as they refer to it, might be brought forward without due consideration of its relevance to the new visit.  The OIG’s current focus is the ‘reason for visit, and the ‘history of present illness’ sections of the case history. First, if you are not familiar with those terms, you are fifteen years behind the times…Literally, fifteen years.  Second, if your EHR is permitting you to pull the HPI from a previous visit into the record for a subsequent visit, we suggest that you ignore that capability and do as health care providers have for 100 years…Enter the data as it is gathered; only enter data that is germane to the reason for visit and to the needs of the patient.  Further, if your EHR permits ‘auto-populating’ entire sections of the patient’s chart, such as review of systems or physical examination, be sure that the final information that appears in the chart represents what the patient needed that day as well as exactly what was done.

As we’ve all learned in health care delivery and in life, ‘easy’ is not always good, and ‘easy’ sometimes is not  the best choice.  Electronic health records are definitely a great tool for gathering and storing information related to patient care and certainly benefit the quality of health care.  However, as with any other technology, new or established, good tools can be used inappropriately, resulting in unintended consequences for the user.

Coding and Medicare Changes for 2012

Charles B. Brownlow, OD, FAAO

Before I start going over the key changes for 2012, how about if you sit down at the computer, go to AOA.org, and order Codes for Optometry.  It will cost you about $135 for the two-volume set. You will receive a brand new 2012 Current Procedural Terminology (CPT), the only nationally recognized source for codes and definitions of all office visits and procedures.  It comes from the AMA, not from Ingenix or PMMC, or PEN…It comes right from the source that is recognized and required by HIPAA.  You will also get a second volume, AOA Codes for Optometry, which provides ICD-9 abridged for the eye, the Documentation Guidelines for the Evaluation and Management Services, the HCPCS codes for materials, and lots of other information regarding medical record keeping. It’s the biggest bargain in eye care…No optometric practice should be without CPT and it must be current. The 2011 or 2001 or 1996 editions will be of no use in the new year!

CPT and ICD-9 Changes, 2012

CPT 92070, fitting of contact lens for treatment of disease, has been deleted.  It has been replaced by two new codes: 92071, fitting of contact lens for treatment of ocular disease; and, 92072, fitting of contact lens for management of keratoconus, initial fitting. Each of these codes is unilateral, billed once for each eye, and each is for the professional services only. The lens should be reported separately, using the V codes or 99070.

92120, tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method, has been deleted.

92130, tonography with water provocation, has also been deleted.

ICD-9 There have been changes in codes for use prior to the definitive diagnosis of glaucoma. 365.0, borderline glaucoma, has been joined by two new codes; 365.00, preglaucoma, unspecified, and 365.01, open angle with borderline findings, low risk; open angle, low risk.  The description of the code 365.02, anatomical narrow angle, now includes new language, “primary angle closure suspect”.  ICD-9 has also added two additional glaucoma codes, 365.05, open angle with borderline findings, open angle, high risk, and 365.06, primary angle closure without glaucoma damage.

In addition to those changes, CPT has added a whole new set of codes to report the stage of each patient’s glaucoma.  These are:

• 365.70 Glaucoma stage unspecified, glaucoma stage NOS
• 365.71 Mild stage glaucoma/early stage glaucoma
• 365.72 Moderate stage glaucoma
• 365.73  Severe stage glaucoma, advanced stage glaucoma, end stage glaucoma, and
• 365.74  Indeterminate stage glaucoma

The glaucoma ‘stage codes’ are reported only when glaucoma has been diagnosed, using codes 365.10-365.13, 365.20-365.23, 365.31, 365.52, and 365.62-365.65. Stage codes are not reported with any of the codes related to glaucoma suspects, 365.00-365.06.  Determination of the stage of each patient’s glaucoma is left to the judgment of the doctor.  For guidance, AOA members can refer to the Quick Reference Guide, Care of the Patient with Open Angle Glaucoma, Table 1.  The guide can be found on the AOA website at http://www.aoa.org/documents/QRG-9.pdf, for viewing, ordering, or for download.

Medicare Fee Schedule

As of December 3rd, Congress has not acted to avert a huge decrease (20-25%) in Medicare payments to providers.  Watch for more news on this issue during December and through early January.  WOA, AOA FirstLook, etc., will all let you know if and when the new fee schedule is final.  We’re all hoping that Congress will set aside the cuts and grant a small increase for 2012, but don’t hold your breath.  And, oh, Happy New Year!  

Questions?  drames@pmi-eyes.com, joycepmi@aol.com, drbrownlow@pmi-eyes.com

As a group, doctors of optometry comprise the nicest bunch of health care providers in the US of A.  We love our patients and we even like each other; well, most of us like each other.  We are very different from other health care professions in the way we value our services, the way we accept insurance contracts, the way we deal with ‘not covered’ services, the way we deal with rejected claims, etc. 

Just think about it, we, far more than any other health care professions:

1. Set our fees way below other professionals’ fees for identical services, partially because we know some of our patients will actually have to pay for those services
2. Provide ‘prompt pay discounts’ at the drop of a hat and ‘hardship discounts’ to anyone who asks (for some offices, just asking is qualification enough!)
3. Accept insurance contracts, medical or vision plans, without reading the contract
4. Accept insurance contracts, medical or vision plans, after reading the contract, complaining to anyone who will listen about the low reimbursements and only partial coverage of our scope of services
5. Consider an explanation of benefits to be the final word with respect to rejected claims and usually don’t bother to refile the claims, even when we find nothing wrong with the original claim
6. Accept an insurer’s interpretation of ‘reasonable and necessary’ or ‘medically necessary’ without challenging their antiquated, slanted view of the importance or relevance of services, which ultimately benefits the insurer, not the patient or provider
7. Neglect to inform our state and national association when we experience treatment by an insurer that smells and feels like discrimination or unfair treatment, based upon who we are not (MDs) rather than upon the services we provide.

So, that should get your blood boiling, hopefully enough to move you to taking some action.  Take a look at the processes inside your practice first; including your fees, your means of choosing codes, your system for accepting and rejecting insurance contracts, your system for handling rejected claims, etc.; and then and only then look outside your practice for battles to fight.

Have a great day!