Article Date: 9/1/2001

When Once Isn't Enough
How to bill for a patient more than once in 6 months, and HCFA changes.
By John McGreal Jr., O.D.

Q I'm getting denials (too-frequent services) when I bill for patients more than once in a 6-month period. Here's an example: 6-22-00/ 92012/366.16/paid; 3-22-01/99212/373.2/paid; 6-28-01/ 92012/ 366.16 denied.

Do I need to use a modifier to receive payment on this last claim? I explained in the note field why I'm seeing the patient, but I still get denials. The same thing happens when I see glaucoma patients to check the effectiveness of glaucoma medications within a 6-month period. What am I doing wrong?

Answer: This situation is frustrating to all of us. Optometrists and ophthalmologists in many states have exactly the same problems. The reason for denial is probably related to the frequency and diagnosis code. The definition of intermediate eye code 92012 is as follows here:

"An evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy."


Because the diagnosis was cataract (366.16) on the first and third visits, you were denied on the third visit because cataract is no longer a "new" diagnostic or management problem. Using the 99xxx E/M codes is often more helpful in these instances, as is using a different diagnosis code, assuming the patient has multiple problems.

While I agree that it's often medically necessary to follow a patient at close intervals for the same diagnostic problem, trying to collect reimbursement for these services by using 92xxx codes often results in denials.

When you're changing medications and assessing the effectiveness of new glaucoma treatments, many carriers ask for the use of the ICD diagnosis code V58.69 (long-term current drug use, high-risk medications) in addition to the diagnosis of glaucoma. This alerts them to the necessity of the visit. Keep in mind that you always have the right to appeal if you feel that you've wrongly been denied payment.

Q Has HCFA changed its organizational structure?

Answer: Yes. The Health Care Finance Administration (HCFA), which administers Medicare and Medicaid policy, has been renamed the Centers for Medicare and Medicaid Services (CMS). The change was announced during a press conference on June 14, 2001.

The new service promises many reforms and improvements, and hopes to be more responsive and effective. It's also committed to providing better service to beneficiaries and doctors.

The agency has been reorganized into three centers of service:

1. The Center for Medicare Management is responsible for traditional fee-for-service programs.

2. The Center for Beneficiary Choices provides beneficiaries with information on Medicare, MedicareSelect, Medicare+Choice and Medigap options.

3. The Center for Medicaid and State Operations focuses on Medicaid and state administered services.


Optometric Management, Issue: September 2001