Formerly known as PMI, LLC

Purchase PMi Services

Frequently Asked Questions (FAQs)

Categories for FAQs:



Dealing with Medicare

Q: Medicare Allowable Charges - How do I know what Medicare allows for 92065?

A: 92065 Medicare relative value for 2011 is 1.17, and the national average Medicare conversion factor is $34.00, so national average Medicare allowed charge for 92065 is $39.78. If you are non-participating provider for Medicare, the limiting charge would thus be about 1.09 x $39.78 = $43.36. Remember, non par providers can bill theirr usual fee but be very careful to not collect more than the limiting charge from the patient. By the way, MDs' fee survey data for 2010 fees indicates $87 at the 50th percentile for 92065. Remember, you can find relative values for all CPT codes in AOACodingToday.com.

Q: Medicare Fees for MDs v. ODs - If the MD survey data shows fees that are higher than our limiting charge can they bill more or are they subject to the same Medicare fees and limiting charges as we are?

A: Very good question. Medicare gets this one right...Regardless of license of provider, Medicare's allowable charges and limiting charges are identical for MDs and ODs...Too bad all payers don't do the same! With non par providers, it doesn't matter what is billed...No provider, MD or OD, can collect more from the patient than the limiting charge.

Q: Cataract Surgery Co Management - The new office I'm working in had a question about the right code and the appropriate fee to charge for the reimbursement of cataract surgery co-management. I am not sure, short of surveying my colleagues. I'm wondering if there is a standard.

A: There are many rules and conditions for billing post op cataract care. The surgeon must put a note in the patient's chart sending the patient back to the OD for post op care. The surgeon must put the 54 modifier on the cataract surgery code on the claim and the OD must put the 55 modifier on the same cataract surgery code on the claim. The date of service is the surgery date. (except Trailblazers, which requires the date of service to be the day after surgery) The OD bills for the number of days she/he is responsible for care during the 90 day post op period. The OD cannot submit the claim until she/he has seen the patient at least once during the post op period. The 90 day post op value is 20% of the entire surgery. Usual fees can be calculated by surveying local surgeons to find an average usual fee for the surgery, and multiply that by .2 to find the 20% number. The daily post op fee would then = (the average surgery cost x .20) / 90. A scenario might be, the OMD returns the patient to the OD on the second day post op. The OD would bill for 89 days, charging 89 x the per day post op fee. Though the OD cannot submit the claim until the patient is seen at least once, there is no need to wait until the end of the 90 days. The OD is paid for the full span of days, even if the OD only sees the patient once.

Medicare reimbursement is quite low, although other major medicals reimburse much closer to usual and customary fees. With that in mind, it’s very important to not base your post op fees on what Medicare pays, any more than it's appropriate to base any other fees on what Medicare pays. Medicare has no intention of paying full usual fees for services. Establish your fees based on what you feel your services are worth, rather than what a payer feels they can get away with.

Payment also hinges on accurate completion of the claim form, so be sure that all the correct information is in the correct boxes as you submit the claims for post op care.

Q: Medicare Billing vs. Other Insurers - We bill Medicare one way and private insurances another (ie Anthem, UHC)?

A: I suggest following national rules; including Current Procedural Terminology, International Classification of Diseases-9th Edition, the Documentation Guidelines and Medicare guidelines; with all payers until a payer informs you that their rules are different than the national rules. The world of third party would be much simpler if everyone complied with the national rules and guidelines, but if you’ve signed a contract with an insurer, you follow the insurer’s rules.

Q: 92000 Series Office Visits with Medicare - When can you use 92000 office visit codes for Medicare and how often can these codes be used?

A: The 92000 office visit codes, intermediate or comprehensive, can be used any time the content of the patient's medical record matches the required elements in the CPT definition for the code. The CPT definition for the comprehensive requires seven elements: case history, general medical observation, external examination, ophthalmoscopic examination (with or without mydriasis or cycloplegia), gross visual fields, basic sensorimotor examination and initiation of diagnostic and treatment program. There is no limit to how many times the 92000 codes can be used per year. The CPT definition for the intermediate requires six elements in the medical record: A new or previously existing problem, complicated by a new problem, case history, general medical observation, external/adnexal examination, other diagnostic procedures as indicated, and initiation or continuation of diagnostic and treatment program.

Q: Fundus Photos in Ohio Medicare - How often can fundus photos (92250) be billed under Ohio Medicare for monitoring glaucoma, diabetic retinopathy, AMD, etc.

A: . We Googled for Ohio Medicare Part B and found the following Local Coverage Determination. I copied and pasted the policy at the bottom of this email. It looks like two years is the standard limit. If you believe it to be necessary, you may do the test more frequently if you first get the patient to sign an Advance Beneficiary Notice so that they will pay you if the payer rules it to be not reasonable and necessary.

The policy is: Fundus photography with interpretation and report, CPT code 92250, is covered when the procedure is performed based on the Local Coverage Determination (LCD) policy coverage criteria described in the LCD titled 'Ocular Photography and Ophthalmoscopy (L7968).'

The complete LCD is available at:

When submitting this service, it is important to note that CPT code 92250 is a bilateral procedure. This procedure cannot be submitted with CPT modifiers 50 (bilateral) or LT (Left) or RT (Right). The LCD limits the covered frequency of this service.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation. Generally, it is not medically necessary to repeat fundus photography more often than every 2 years for follow-up of stable glaucoma. Repeat photographs for retinopathy are rarely necessary. Medical Record Documentation requirements: The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available to Medicare on request.

Appropriate photographs must be in the patient's medical record when CPT code 92250 is billed and available to Medicare upon request. Service that do not meet medical necessity and/or exceed allowed frequencies may require the use of an Advance Beneficiary Notice (ABN). ABNs allow patients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of 'not reasonable and medically necessary. ABNs must be issued using the standard CMS form. Access the ABN-G and other background information from the CMS Web site: http://www.cms.hhs.gov/BNI/01_overview.asp.

If you utilize ABNs, they must be issued in advance. Maintain the original in the patient's medical record. Provide the patient with a copy of the signed notice. If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Modifier Lookup tool on the Ohio and West Virginia home pages for information on HCPCS modifier GA:

Q: How Many Diagnosis Codes on a Claim? - I attended a Medicare workshop where the speaker told us that Medicare preferred that we put only one diagnosis per service on our claims (except for diabetic retinopathy). If a patient has two medical diagnoses, I have been submitting only one of them on my claim, although both are noted in the chart. Is this correct? Or should I put all diagnosis codes on the claim? Thank you.

A: . ICD-9 guidelines suggest that you put any and all diagnosis codes on the claim that are related to the day's visit and to each specific procedure. All of those should be on the medical record for sure. Medicare and most other insurers don't look past the first Dx code listed on the claim and assigned to each visit and procedure on the claim, so it is probably all right to just put one Dx; being sure that it is the one most closely related to the reason for the visit or for the procedure being reported.

Q: Tips Regarding the Advance Beneficiary Notice - In one of the webinars Dr. Brownlow mentioned "Advanced Beneficiary Notice" Could you elaborate on this and if you have a sample I would appreciate seeing it.

A: . The Advance Beneficiary Notice was created by Medicare. It is used in cases where the doctor needs to do a service that is covered by the insurer (e.g., Medicare) but the doctor is not sure whether the insurer will allow it or disallow it as being 'not reasonable and necessary'. (The old term was 'not medically necessary.') For example, a payer will rule a covered service to be not reasonable and necessary if the diagnosis code doesn't seem appropriate for the service, or if the service is being billed more frequently than the payer’s policy provides. Once the payer rules a covered service to be not reasonable and necessary, the doctor will not be paid for the service by the insurer and cannot collect from the patient unless the patient signed an Advance Beneficiary Notice prior to the performance of the procedure.

The Advance Beneficiary Notice (ABN) permits the doctor to:

  • Explain the situation to the patient ("This test is very important but the insurer may not pay for it")
  • Provide the ABN to the patient for their signature. - By signing the ABN, the patient agrees to pay for the service in case the insurer does not. The ABN must be signed before the test or service is provided to the patient.
  • Once the ABN is signed and the test is completed, the claim for that procedure needs to have the GA modifier attached, indicating to the insurer that you have the signed ABN on file.
  • Then, if the insurer rules the service to be not reasonable and necessary, the fee for the service is moved to the 'patient's responsibility' column of the explanation of benefits, and you collect from the patient.

Refer to the CMS website or the AOA website for a copy of the ABN, or send an email to askthecodingexperts@aoa.org