Frequently Asked Questions (FAQs)
Categories for FAQs:
Dealing with Private Insurers
Q: Billing Medical or Vision Plan - I was in a discussion of medical vs. vision plans and when to bill each and I believe that the decision should be chief complaint driven. If a person with diabetes is in our office for their annual health check and they have VSP, how should it be billed (assuming the provider is a panel member for both medical and vision). I feel that it needs to go to the medical insurance with vision as a secondary plan. Just like any other secondary plan, VSP could be billed for non-covered services. Also, if the patient has a high deductible HSA, it will come back and then you could send it to VSP. Confusing, not?
A: I agree completely that the decision is based on the reason for the visit and not upon the diagnosis, unless the payer's contract says otherwise. If the patient comes in with systemic diabetes and wants to be checked for any eye problems, it should be billed to the major medical. If the patient comes in wanting a VSP exam and you find out during the history that she has Db, it should be billed to VSP, with any subsequent, diabetes related tests and visits billed to the major medical. This is not easy, especially with patients becoming savvier and more insistent that you bill whichever plan has the lowest deductible.
Honestly, I think that even the most committed doctors occasionally give in and bill the way the patient wants them to, just to keep the patient as a patient. Consistent treatment of these questions is very good and certainly the ideal. I also believe that this situation will become an even bigger issue as deductibles rise on the major medical side and as patients become even more involved in their insurance decisions. The office with firm policies, consistently applied and clearly communicated with patients will do just fine.
Q: Cataract Surgery Co Management - We are still having problems co-managing cataract surgery with some insurances. They seem to pay us on a per visit basis, rather than based on the number of days we're responsible for the patient's post op care.
A: It sounds like the plan you're referring to is a Medicare Advantage plan or one of a few major medical insurers that don't follow Medicare's protocol for billing post op care. Because of the very broad language of the bill that created these plans, companies are free to do some things differently than straight Medicare Part B. In Part B, of course, the surgeon applies the 54 modifier to the surgery code and notes in the patient chart that the patient is returned to the OD on a set date for post op care. The surgeon is paid for that portion of the 90 days that she or he is responsible for. The OD applies the 55 modifier and is paid for the days that he or she is responsible for the post op care. Many Medicare Advantage plans have had little or no experience with the 54 or 55 modifiers, so tend to get creative in the way they pay for post op. Ideally, doctors and staff would call the insurer and complain and explain right away so that the payer could choose to handle post op care just like Part B does. I doubt much of that has happened. Or, the plans have heard complaints and explanations and don't really care. Because of the legislation, I doubt that the Centers for Medicare and Medicaid Services would try to do anything to rectify this, as long as the total payment to the OMD and OD would be no more than the total allowed for the surgery when the 54 and 55 modifiers are not applied.
So, what to do? I guess the only option is to try to find a real live person at the company to speak with, ascertain what their policy for post op care actually is, explain what Medicare Part B's policy is and ask them to change it to match. If they will not change to comply with Medicare's policy, you will have to adapt to what they require. The most common option I've seen is that the insurer requires the doctor to bill for each visit on a separate claim, using the appropriate office visit from the 99000 or 92000 series.
Q: Dealing with Rejections - We have an insurance company that is constantly rejecting claims, will not provide clear reasons for the rejections, is impossible to reach on the phone or with emails, never pays within 30 days, and refuses to reimburse us for some covered services clearly within our scope of practice. What can we do?
A: About the only recourse when you get the run around from a payer is your state Commissioner of Insurance. The plans are not supposed to be confusing, have overlapping coverage, etc., but many do. When you cannot get a straight answer from the payer, the Commissioner should know about it. Google your state's Commissioner of Insurance and use the Contact Us feature on their website or call them. Be prepared with good documentation of the problems you're having with the insurer and inform your state optometric association, too. Other members may be experiencing the same challenges with the insurer.
Q: Bill Your Usual Fees to Insurers - My staff often gets confused trying to charge each insurance company correctly in order to maximize reimbursements. How can we keep track of all the various fee schedules?
A: It's important that you keep all the insurers' fee schedules on file, but you should always bill your usual fee; irrespective of what the insurer pays. I got the impression from your question that you may have billed what you thought the payer would pay. It's important to bill your usual charge to keep it simple in your practice and less confusing for staff and for patients. Just as important, most insurance contracts, including Medicare, require that you bill your usual charges and they then pay the lesser of the contracted fee schedule amount or your charge. Doing otherwise and billing more just because they pay more, would violate most insurance contracts.
Q: Use of 99000 vs. 92000 Codes for Visits without Detailed Treatment Plan - I work in a multi-specialty clinic. My coding department has recently informed me that: If I see a patient who presents for an exam and refraction and there is no medical or refractive treatment plan (other than return in one year to monitor) I should use one of the E &M codes. They state that if there is no initiation of treatment that I should not use a 92012 or 92002 even if their reason for visit is "eye exam". Is this true?
A: As you probably know, the CPT definitions for the intermediate and comprehensive ophthalmological services are pretty subjective and general, but each of the definitions does include several required elements, including 'initiation (or continuation) of diagnostic and treatment program.' That requirement has been part of those definitions for many years, but it has been largely unnoticed by doctors, coders and insurance company auditors until the last ten years or so.
The problem with the requirement is that it is pretty vague, leaving much to interpretation by the doctor or coder choosing the code and by the insurance company auditor when an audit occurs. As is common in CPT, the definition is followed by an 'example'. Some auditors will use the example as though it is part of the definition and interpret it very conservatively, others will understand that it is an example, not intended to cover all possibilities, and interpret it more broadly.
The example states, "Initiation of diagnostic and treatment program includes the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services." In my experience, most auditors take a broad view and accept many common things doctors do with and for patients, such as instructing the patient to return to the office, ordering and/or performing additional diagnostic tests, renewing medical Rxes, ordering new spectacle Rx, ordering surgical procedures, considering referral to another specialist, etc. Very few auditors interpret the example very narrowly, sometimes even leading to rejection of the use of 92002, 92012, 92004, or 92014 unless a new medication was prescribed.
Personally, I think the narrow interpretation is too restrictive. If one really wanted to look carefully at the example, one could not choose these codes for anything unless all the elements of the example were performed on the patient; Rx a med, arrange additional testing or treatment, consultations, lab tests and radiological tests. That would be very rare indeed. Given the fact that the intermediate and comprehensive are easily the most commonly used codes by ODs and OMDs, I doubt the CPT Editorial Board intended for such a limited interpretation.
Another consideration is that many vision plans require you to use the 92000 codes for visits without a medical reason. In such cases, if you had to use 99000 codes you would not be paid by the vision plan.
The decision of where to send the claim should be based on the reason for the visit. If the patient enters without a medical reason or complaint, the claim goes to the patient and/or the patient's vision plan, using 92000 or 99000 codes. If the patient enters the office with a medical reason or complaint, the claim should go to the medical insurer, using either the 92000 or the 99000 codes. In all cases, the care should match the needs of the patient, everything should be carefully record in the patient's record for the day, and the codes should be chosen by matching the content of the record with the details of the CPT definitions for the codes.
If all of that is done, all will be well, even in an audit.