Frequently Asked Questions (FAQs)

Categories for FAQs:

Consistent Coding for Procedures and Diagnoses

Q: Billing Special Add On Codes with Office Visits - I understand that we can add 99056 to whatever 92000 or 99000 office visit we choose when we provide care for a patient in her/his home.

A: Code 99056 is used to report "services typically provided in the office, provided out of the office at request of the patient, in addition to basic service”. You won't find any Medicare values for that series of codes, as Medicare never pays for them, though many other insurers do. Facility fees refer to services provided within hospitals, etc. and the non-facility fees are the ones that apply to services provided in clinics, offices, private homes, nursing homes, etc. Facility fees rarely pertain to services provided by ODs.

Q: S Codes - Please provide us with some clarification on documentation for billing S0620; routine exam with refraction.

A: S0620 is defined ‘routine ophthalmological examination, includes refraction, new patient.' S0621 is the same code for established patients. These are HCPCS codes, not CPT, and as a result, most doctors continue to use the 99000 or 92000 visit codes, combined with 92015, refraction, to report their eye care visits. Most eye doctors are more comfortable using the CPT codes for reporting their visits and therefore the use of the S codes is pretty low.

The word 'routine' in the definition may be understood to mean that the visit had no medical reason/chief complaint/presenting problem. Doctors who choose to use the S codes would use them whenever there was no medical reason for the visit, whether the patient has insurance to cover the visit or not. This is further complicated because most of the vision plans that cover the 'non medical visits' don't accept the use of the S code.

The only advantage I see in the S codes is that offices can establish fees for their 99000 and 92000 office visits as if they are always used for medical cases, reserving the S codes; in most cases with a lower fee; for the visits without a medical reason.

Q: Billing for Cycloplegia - Is there an additional procedure code that can be used when performing a cycloplegic refraction during a comprehensive exam? Thanks

A: No. The definition for the comprehensive ophthalmological service (92004/92014) includes 'ophthalmological examinations'...with or without mydriasis or cyclopegia. There is some confusion that it’s all right to use 92225, extended ophthalmoscopy to indicate that you’ve used mydriatics or cycloplegics, but 92225 is actually reserved for special situations where the patient’s diagnosis warrants a very detailed examination of the retina. Most payers require a detailed retinal drawing as well as at least two examination procedures be done (eg BIO plus Volk lenses at the slit lamp) in order to be considered extended ophthalmoscopy.

Q: Imaging - When billing for OCT is it better to bill RT and LT modifiers or 50 when we’re doing it on both eyes at a single visit?

A: It is customary to list 92135 on two separate lines, with the RT and LT modifiers, respectively. Note: Beginning January 1, 2011, CPT no longer contains 92135. The code has been replaced with three other codes: 92132, anterior segment imaging, 92133, posterior segment imaging, optic discs, and 92134, posterior segment, maculas. The codes are now bilateral, meaning that reporting the code once covers both eyes, and the fees are Medicare reimbursements are considerably lower than in 2010 and before.

Q: Rule Out Exams for High Risk Meds - What are the best ICD-9 and CPT (e/m vs 920xx) codes to bill for ruling out toxicities to medications (i.e. Plaquenil or Interferon)

A: We suggest using three ICD codes: 1) The code for the condition (e.g. rheumatoid arthritis with Plaquenil); Second, V58.69 (long term use of high risk meds); Third, the E code for the medication last.

Q: Punctal Plugs - What is the best way to bill for punctal plugs when doing collagen on one visit and silicone on a separate visit, to the lower right and left only? When doing both lowers do I need a -50 or -51 modifier? Is the same dollar amount charged per eye, or the second at 50% of the first when billing. Thanks.

A: Insertion of the collagen or temporary plugs can be reported using the 68761 for each eye, just like the permanent plugs. One option (because of the huge difference in the cost of the plugs) is to simply bill an office visit without the 68761 when you insert the temporary plugs, and reserve the 68761 for permanent plugs. Another option is to bill the 68761 with a 52 modifier and reduce the fee to reflect the reduced cost of the plugs, reserving the full 68761 for the permanent plugs.

So, using the 68761 to report closure of two lower puncta with plugs would look something like this on a claim form:

  • 68761 E2 1 unit
  • 68761 E4, 51 1 unit

Medicare pays 50% less for the second plug inserted at the same visit. I recommend reducing the fee for the second plug but by whatever percentage you feel is appropriate, like maybe 25%. That way you express your opinion as to the value of the second procedure, relative to the first, and then the payer expresses its opinion. I prefer that order.

68761 is the only minor surgical procedure in eye care that still has a 10 day global period, meaning that if you use the 68761 to report the temporary plug, you would not insert and bill for the permanent plug until at least ten days have passed.

One final caution…68761 is frequently audited, as it has become so common. Be sure to follow protocols when deciding to use plugs, such as doing tests to diagnose the presence of dry eyes, trying other options first (eg OTC meds), including an order for the plugs in the patient’s record, recording the surgery in the patient’s record as well as orders for follow up, etc.

Q: Office Visits and Surgery Codes - This is a pretty basic coding question, but I can't seem to find the right resource to get this billed right. Same day: Comprehensive exam, refraction, and epilation for left upper lid. 92014, 92015, 67820 E1 - Where does the -25 go to show that epilation was a separate service done the same day as exam to get paid for exam and epilation properly.

A: .First, it has to be clear that the surgical procedure, 67820, is indeed separate from the office visit, as CPT makes it clear that each minor surgical procedure includes an office visit. If the medical record for the office visit includes details unrelated to the surgery, showing that is separate, the visit would be billed. For example, maybe the reason for the visit was something other than 'scratchy eye' or 'Those scratchy lashes have grown back.' Maybe the patient is in for a glaucoma check up and you find lashes scratching the cornea during biomicroscopy. The visit is billed with the glaucoma Dx code and the 25 modifier to indicate the visit is unrelated to the surgery. The 67820 is billed with the trichiasis Dx code. The epilation will not need a modifier.

Q: Documentation for Ordering Tests and for Interpretation and ReportI am questioning the documentation required for ordering and for the I & R of diagnostic tests. We were told for ordering a diagnostic test we needed to document

  • Ord (for order)
  • Name of Test (ie RP for retinal photos)
  • Diagnosis
  • Date requesting test (ie same day)
  • Expiration Date for order
  • Physical signature (electronic was not satisfactory but was still being considered). I want to order w/o handwriting and scanning an order and this would prohibit it. For Interpretation & Report, a lecturer told us we need to document
  • Name of Test
  • Results
  • Reliability (ie 1-4)
  • Plan (ie re-do in 6 mos)
  • Physical Signature
We certainly want to be compliant…What say you?

A: I think it is important to continue to do things as you are (as much as possible) while complying with the rules that apply. I believe that ODs have traditionally been pretty good about writing orders...We just didn't think of them as being orders. The same is true with 'interpretation and report.' The outline that you provided is certainly thorough and probably reflects what you are already entering in your chart. Before the Documentation Guidelines of 1997, much of this would have been part of the Assessment and Plan of the old SOAP format for medical records.

By the time you are 'ordering' the test, the record will already have the Dx or the rule out Dx recorded...That's the reason for ordering the test. The date is already on the chart, no need to repeat it, and every record requires the doctor's signature (written or electronic), so there's nothing new there, either. I would consider the expiration date to be unnecessary, since the tests are being provided onsite, rather than at a remote testing site.

As for the Interpretation and Report, Dr. John McGreal has long said the notes should include 'What you did, why you did it, what you found, and what you plan to do about it'. I like that a lot and I'll bet it would be accepted by nearly every reviewer/ auditor, other than those just looking for something to argue about. Even then, argue away! My suggestion for I & R is even simpler; the 3-Rs...The Reason you are doing it (the Dx, suspected Dx), the Results of the test, and your Recommendations following those results (management options).

The key is to develop internal protocols that protect the patient, identify why the test is being done and when, ensure good follow through with necessary testing, make clear record of recommendations resulting from the tests. I think all of that is possible in nearly every case in twenty words or less.

Q: A Set of Questions Related to Billing for Contact Lenses - What is the proper way to code for contact lens exams? Patient comes in for routine eye exam and CL fit, code 92004/14 AND 92310?

A: Yes. And, if you have done one, you should bill for refraction (92015), too.

Q: What is the proper code for the first follow-up exam after the contact lenses are dispensed?

A: The follow up visits may be included in the 92310, as its definition includes "medical supervision of adaptation". If you arrange with the patient to charge separately for follow up visits, each visit should be coded based upon the elements of the history, physical examination, and medical decision making that are completed and recorded in the record for the day.

Q: How about when a patient presents for a routine eye exam, doesn't want CL's at that visit, but decides a month down the road they now want CL's? Would I use the code 92310 for that, too?

A: You might need to do a limited examination to be sure nothing new had popped up in the intervening weeks. If not, the 92310 would cover the fitting and supervision of adaptation, without another visit being billed.

Q: How about if the patient has already been fit into CL's by another provider and just wants current CL's updated? Would I use code 92310 here, too?

A: I would apply the same protocols for a refit as for the new patient. You will need to do a pretty thorough exam to rule out vision and eye health problems, do a refraction, choose the lenses, supervise the adaptation, etc. It sounds like you would be billing an office visit, with the visit code chosen based on the components the exam and the medical record, along with the 92310. Another consideration is that the 92310 is defined such that it may include the supply of the lenses or you may separate the value of the lenses from the fitting and bill for the lenses separately, using the V code that most closely matches the type of lenses you are prescribing.

Q: Records Storage - How long to we need to keep invoices and receipts for our practice? How about fee slips?

A: This is a matter of state law and also an issue as to whether the state considers financial information to be part of a patient's medical record per se. The most common time requirement for medical records and related information is six or seven years. I always suggest ten years; just to be sure you are covered. Your state association might be able to provide some insights here, too.

Q: New vs. Established, Revisited - What determines whether a patient should be coded out as a new or an established patient? For example say a patient comes in for a 99203 and six weeks later wants an exam-should they be considered new?

A: A new patient is described as one who has not received services from this doctor or another doctor of same specialty (which means either an MD or an ophthalmologist) in this office or another office with the same ownership, within the previous three years. In the case you describe, the second visit, six weeks after the first visit, would be reported using established patient codes.

Q: Serial Tonometry Instead of Pachymetry? - Question: I am using CPT code 76514 for pachymetry but it is always rejected stating that this "requires a referring NPI". A colleague told me to use CPT 92100. It is my understanding that the 92100 code is for serial tonometry. Thanks for your help.

A: Your colleague’s advice is not good...No way would you bill 92100 unless you did it. Also, 92100 is a very specific test, totally different than pachymetry. 92100 is also often the target of audits because it is frequently misused. (It seems quite a few doctors use it to report applanation tonometry, which of course is included in the definitions for office visits and is not billed separately.) As for the comment on your claims regarding a referring NPI, it is important that you put your name and NPI on the claim as the referring doctor (box 17) and that you indicate 'no' in box 20, as no outside lab is used for the test. I’ll bet if you include your NPI on every claim that includes a diagnostic or surgical procedure, the problem will go away and 76514 will be paid.

Q: Surgeon Not Sending Patient to OD for Post Op Cataract Care - I would like your assistance with a situation our office is having. Our staff calls each patient’s insurer for eligibility. When the patient is sent for the surgical evaluation, she calls the patient's insurance to see if we can co-manage the patient's post surgical care. I am talking about commercial insurance, not traditional Medicare. In some cases, the insurer says we can co manage although some surgeons say that they cannot co manage the care. I know insurance companies give double answers, but how can our office get a yes from the insurer and a no from the surgeon? We would like our patients under our care for follow-up. I appreciate any ideas you can share.

A: Most surgeons are sending patients back to ODs for all or part of the 90 day post op period following cataract surgery. It is up to the surgeon, because if the surgeon does not add the 54 modifier to the surgery code, the OD will be locked out of any payment for the post op care. The motivation of each surgeon varies, I'm sure. The key is that the decision to share post op care should be based purely on the patient's needs...What is best for the patient. This may require some discussion between the ODs in your practice and the surgeons that you refer to.

Q: Informed Consent for Surgery and Procedures? - My question is about informed consent. Is this necessary for all minor surgical procedures such as epilation, foreign body removal, lacrimal dilation, anterior stromal puncture, etc.? Do we need to fill out a detailed post-operative report for minor surgical procedures? Also is informed consent necessary before examining minors?

A: I would be sure that there is a clear 'order' in the patient’s chart for the surgery and I think it is a good idea to have the patient sign a simple informed consent form before performing the procedure. The record should include notes about what you did, what the outcome was, and that you instructed the patient regarding any post op concerns, follow up visits, etc. I don't think the order or the post-surgical report has to be very long or detailed. As for getting an informed consent from parent or guardian before treating a minor, that is another good idea. Again, keep it short and simple to make it very easy to comply with consistently.

Q: Billing for Visit and Procedures Related to Suspected Conditions - If I have a patient with background diabetic retinopathy, macular drusen, visually significant cataracts with decreased vision, and I run a retinal scan to look for foveal edema or SRNV, can I use the diagnosis codes of retinal edema and/or wet macular degeneration if the scan is negative? A second example is a patient concerned about recent onset of flashes and floaters. Do I use retinal detachment as the diagnosis code since that is what I am looking for?

A: It is inappropriate to use any diagnosis code unless the patient actually has the condition. I would suggest using the diagnosis code for the conditions that the patient actually has, assuming that those diagnoses are germane to the day's visit. In your first example, you would report diabetic retinopathy and possibly macular drusen. For the second example, you could use 379.24, vitreous floaters, with V80.2 as the second code, indicating you're looking for other eye problems. V80.2 is used to indicate you're looking for an ophthalmic condition other than glaucoma (V80.1 is used if you're looking for glaucoma). Understand that some major medicals may not pay for screenings for medical conditions such as detached retina, no matter how you put it on the claim. For that reason, you should carefully explain to the patient why the test is necessary and have them sign an Advance Beneficiary Notice prior to doing the test. That way, if the payer denies it, you'll be paid by the patient.