Article

BUSINESS: CODING STRATEGY

CODING FOR RETINAL EXAMS

GET COMPENSATED FOR PROVIDING THE BEST CARE TO YOUR PATIENTS

IT SEEMS today that much of the excitement in eye care is focused (no pun intended) either on the front of the eye, with ocular surface issues, or at the back of the eye, with retinal disorders. Technology is rapidly changing the methods and techniques used when examining the retina for disease. Today, devices with a single footprint provide a high-resolution fundus photograph (92250), an OCT of the optic nerve (92133) and retina (92134), an autofluorescence image of the retina (92250) and an OCT-A angiography (92134). Many of the tests with different purposes and outcomes are coded with the same CPT code. Therein lies some of the pitfalls that may tempt one to code incorrectly.

Another example: Because many of these devices capture all images simultaneously, one can easily run afoul of the NCCI edits (National Correct Coding Initiative) if coding and billing for some of these procedures on the same date of service.

It is critical to know the rules.

BACK TO BASICS

Let’s revisit some basic but critical issues with a retinal examination and coding for special ophthalmic testing.

  1. Be aware of dilation requirements. 920XX codes do NOT require dilation according to the CPT, but are listed as “often includes, or as indicated.” When the retinal components of a single system eye examination are performed, they must be performed through a dilated pupil unless contraindicated because of age or medical reasons, according to the 1997 CMS E&M Guidelines that govern any 992XX code. Keep in mind that good medical record protocol dictates that the dilating agent(s) should be listed in the electronic health record.
  2. Establishing medical necessity. Since many of these devices capture all images simultaneously, document the medical necessity for the record prior to capturing the image. This should be clearly stated in the assessment and plan of any office visit that determines the need for additional testing. The specific test dictated by this necessity will be the one performed, interpreted, coded and billed.
  3. Laterality is important. With the ICD-10 requiring additional specificity of laterality, know the definition of the specific CPT code utilized. For example, OCT is defined as being unilateral or bilateral, which means one would code it the same whether performed on one eye or both and would bill with units of one. In comparison, fundus photography is defined as being bilateral, which means the reimbursement value is based on both eyes being imaged. However, if there is only medical necessity to take an image in one eye, and you are using a diagnosis that specifies single eye laterality, you will have to append the fundus photography code with modifier -52 (reduced services) and an RT/LT modifier to indicate which eye the procedure was performed on.
  4. Interpretation and report is critical. To fulfill the CPT definition of any of these tests, this must be documented in the medical record. See September’s column, at http://bit.ly/2Im1Rtt , for specifics on what is needed.

REALIZE THE POTENTIAL

Follow these basic, but important guidelines to utilize technology to its fullest potential and get compensated for providing the best care to your patients. OM