Article: Turning Wellness Exams into Medical Exams for Increased Reimbursement

[Robert Rebello]

If a refraction is billed as well as the comprehensive to the medical insurance, and the refraction is denied, can you then bill the vision plan for the refraction?

Wayne:

You should never bill refaction to medical. It will almost always be denied. Start with refraction billed to weelness. Then bill medical to medical insurance

[Robert Rebello]

Should not have been denied if you waited for the global 10 day period between procedures.

Mark is right on on this. One additional comment the global waiting period is the days between procedures. Do not count either of the procedure days for waiting period.

[Robert Rebello]

Thanks for such an informative webinar.Is there ANY ocular diagnosis that would increase a patient's medical premium? I heard you comment that its not like car insurance where a diagnosis will increase their fees, but don't people with certain health conditions (diabetes, hypertension, cancer...) have to pay more for medical insurance?

Tammy

I have not heard of any examples of this occuring. But remember if they have such a condition, it will be billed through their Primary Care Physician. You will not be exposing them.

[Robert Rebello]

I will try to reply to all of the comments or questions before I leave. Whatever I do not get to, I will check when I return from London.

[Ken Elder]

Wayne:

You should never bill refaction to medical. It will almost always be denied. Start with refraction billed to weelness. Then bill medical to medical insurance

That is not my experience. Many plans here in Connecticut do pay for a refraction, usually around $30 even with a medical diagnosis code. We always submit it...if we get paid, great. If we don't then it's much easier to bill the patient because they clearly see the denied service on an EOB.

[mark botwin]

Wayne:

You should never bill refaction to medical. It will almost always be denied. Start with refraction billed to weelness. Then bill medical to medical insurance

Bob,
A few things,
You can't bill VSP for refraction alone. You need a denied eob but they will only pay $12 anyway and $10 was the patients copay so it's not worth the postage for a $2 reimbursement .

I'm amazed you agreed on my split billing Scode to vision plan and 99... to the medical. I thought you would cream me on that one and only recommed billing a 92015 to the vision (after getting a denial for 92015).

Best regards to you and Noel. Did not make VEW this year as I plan to go to the east coast one as my OD son #2 is in Brooklyn doing a residency with Dr. Fingeret. Have fun in London.

[mark botwin]

Hi Bob,When I perform an OCT on a plaquenil patient, I use the diagnosis code V58.69 and it is denied. I get paid if I use the same code for visual fields. What am I doing wrong?

OCT not allowed for v58.69 in our area only photos and VF.

[Ken Elder]

OCT not allowed for v58.69 in our area only photos and VF.

Again.....that's yet another perfect example of why I never attend coding/billing seminars or engage in many of those discussions on this or other forums.

There is no "right" way. What works in CT doesn't work in NM but may work in IL. And some things it's the other way around.

Basically what you need to do is find out what works in your area. Ask your state association. Ask friendly competition. Pay for the billing manager of the local big ophthalmology practice in town to have a weekend at a spa and then pick their brain.

[mark botwin]

Again.....that's yet another perfect example of why I never attend coding/billing seminars or engage in many of those discussions on this or other forums.

There is no "right" way. What works in CT doesn't work in NM but may work in IL. And some things it's the other way around.

Basically what you need to do is find out what works in your area. Ask your state association. Ask friendly competition. Pay for the billing manager of the local big ophthalmology practice in town to have a weekend at a spa and then pick their brain.

Just buy Bob's program EYECOR. It's terrific and has your local medicare approved procedures for each diagnostic code.

Just remember it's according to medicare and not all of your local medical plans. You may get a local medical denial and you may need to call them to see if they made a mistake or if they just don't follow your areas medicare guidelines.

[Steven Nelson]

That is not my experience. Many plans here in Connecticut do pay for a refraction, usually around $30 even with a medical diagnosis code. We always submit it...if we get paid, great. If we don't then it's much easier to bill the patient because they clearly see the denied service on an EOB.

Agreed on all points

[Mark Horwitz]

That is not my experience. Many plans here in Connecticut do pay for a refraction, usually around $30 even with a medical diagnosis code. We always submit it...if we get paid, great. If we don't then it's much easier to bill the patient because they clearly see the denied service on an EOB.

Ken,

I think it depends on the state. In NJ, billing refraction not only gets the refraction denied, but the entire exam!!!! They automatically reinterpret the 99xxx or 92xxx code as being "routine" and deny it. The only time they will pay the refraction and not deny is if the patient has a "routine" eye exam benefit.

We always find out of the px has a routine benefit. If not, we never bill refrsction to the med ins.

[mark botwin]

Bob, (or anyone else care to comment). I sent this email to a few friends for comment and as usual, the coding and billing debate continues. These are a few responses from 3 OD's.


"If you use Eyecor program as I do, you can look up most medications and check for high risk ophthalmic manifestations of most common meds. Take Lipitor. as an example. Under potential severe complications are listed (amongst others) intraretinal hemorrhages and glaucoma. Bob says you can then use V58.69 as a secondary dx and procede with the approved tests allowed like VF and photos, and color vision. As you know Eyecor is medicare specific for our area. As I never have had a V58.69 denied I believe what he says. What a potential windfall for our practice. .


Others disagree about doing these as routine tests and billing them unless you saw something that would warrant the additional testing. Some feel the these tests are diagnostic and should be done as medicare approves them to be done to help determine if a problem exists.

**Just being on lipitor is not enough to warrant a VF. Now, IF you see intraretinal hemes, then go for it. Have a blast and get paid for what you are worth. However, to do it just because it is covered I think sets you up for some recoupment down the road when audited.

***OK. but when you have a plaquenil patient don't you do VF and photos? I do, even without seeing changes on ophthalmoscopy.

****I retort two things:
there is a standard on doing vf tests on Plaquenil patients. Such a standard does NOT exist on Lipitor. Remember, your documentation and treatment must be consistent with that of your local area peers.

*****We'd have to look at the LCD regarding V58.69 to better determine the risk of billing tests for every drug that has potential for severe ocular adverse effects. There are also AAO guidelines for Plaquenil, but not Lipitor as far as I know of. Much like malpractice, if the testing is usual and customary for most practitioners in the speciality, it would probably fly, but the LCD is still the best guide. An audit would be generated if the profile for one's office if it is substantially different form others in the area.


A good point...we can't bill photos in most cases unless there is something to document other than a normal state. Confusing the issue is that historically we have been able to bill photos for Plaquenil screening without disease being evident.

What say you Bob?

[AdminWolf]

just a reminder -- bob is getting on a plane to europe, so his responses may be delayed a bit.

i'm going to do my best to have the archive up quickly -- like within the next day or two so everyone can take a look at the lecture.

cheers

adam

[Steven Nelson]

Ken,

I think it depends on the state. In NJ, billing refraction not only gets the refraction denied, but the entire exam!!!! They automatically reinterpret the 99xxx or 92xxx code as being "routine" and deny it. The only time they will pay the refraction and not deny is if the patient has a "routine" eye exam benefit.

We always find out of the px has a routine benefit. If not, we never bill refrsction to the med ins.

It's definitely state dependent because in Texas, medical plans (BC/BS, UHC and some local plans like Christus to name a few) will pay for refractions in amounts ranging from $30 to $55 if linked to a medical diagnosis.

Regardless, it's very helpful to have the patient see it denied on their EOB. I used to have a LOT of post-reimbursement discussion because I charged them $x, but their EOB said their responsibility was $y and they NEVER understand how figuring out their prescription isn't part of an "eye exam". It's just better housekeeping for the amount you charge be equal to the amount Medicare has under "patient responsibility".

[Ken Elder]

Ken,

I think it depends on the state. In NJ, billing refraction not only gets the refraction denied, but the entire exam!!!! They automatically reinterpret the 99xxx or 92xxx code as being "routine" and deny it. The only time they will pay the refraction and not deny is if the patient has a "routine" eye exam benefit.

We always find out of the px has a routine benefit. If not, we never bill refrsction to the med ins.

You're right. That's the point I'm making. This whole billing/coding thing varies from state to state and even within some states.

Attending coding/billing seminars by national speakers or at national CE events is not likely to get you answers you need. You need to figure out what works in your particular area with your particular carriers.

[AdminWolf]

The video archive is up, it is raw as I didn't have any time to work on the audio, etc.. but since this was such a big show I figured it was best to put it up as soon as possible

enjoy!
adam

[Jim Levinson]

Bob - is diabetes alone a justification for fundus photos? (250.00) - if the patient tells you their Blood sugar is poorly controlled , is that enough justificiation for fundus photos (250.02) If not - then how do the telemedicine schemes work? I am referriing to where a fundus camera is put into a internal medicine office and they take a photo and the photo is sent to a reading center. what justificiation does this scheme use for billling? Thanks for a good lecture? jim levinson, O.D.

[Steven Nelson]

Bob - is diabetes alone a justification for fundus photos? (250.00) - if the patient tells you their Blood sugar is poorly controlled , is that enough justificiation for fundus photos (250.02) If not - then how do the telemedicine schemes work? I am referriing to where a fundus camera is put into a internal medicine office and they take a photo and the photo is sent to a reading center. what justificiation does this scheme use for billling? Thanks for a good lecture? jim levinson, O.D.

My understanding is no because you photo to document pathology, not its absence. I'm not Bob, but I'm pretty sure I'm right on this one.

[Jim Levinson]

My understanding is no because you photo to document pathology, not its absence. I'm not Bob, but I'm pretty sure I'm right on this one.

Why can't a fundus camera be used for diagnoses - for example autoflourescence is an excellent tool for optic nerve drusen, IR viewing is excellent for a nevus. I have missed things on ophthlmoscopy that i have seen on a photo. the camera in my opinion is an excellent tool dor diagnoses and not just documentation.

jim levinson, O.D.

[Richard_Hom]

I believe the issue is whether the Food and Drug administration has certified the fundus camera as a diagnostic tool. As of today, I do not believe any of the funndus camera are certified to diagnose disease.

In the case of angiography, you are interpreting the results to make a diagnosis. Likewise, a visual field unit gives a read out and the doctor has to interpret the results. The FDA, in the case of field units had to certify the normative databases.

[Steven Nelson]

Why can't a fundus camera be used for diagnoses - for example autoflourescence is an excellent tool for optic nerve drusen, IR viewing is excellent for a nevus. I have missed things on ophthlmoscopy that i have seen on a photo. the camera in my opinion is an excellent tool dor diagnoses and not just documentation.

jim levinson, O.D.

While I agree that it's hugely useful in diagnostics (especially in subtle macular findings), it's not reimbursed as a diagnostic instrument. It's for documentation. In fact, you're not supposed to rephoto things that haven't changed even if the presentation is pathologic. For example, when someone has optic cupping, it's appropriate to take photos, but subsequent photos have to document a CHANGE in presentation.

[Robert Rebello]

Hi Bob,When I perform an OCT on a plaquenil patient, I use the diagnosis code V58.69 and it is denied. I get paid if I use the same code for visual fields. What am I doing wrong?

I am sorry that I did not get to this reply before my trip.

This applies to any medication with a severe side effect. As we show in EyeCOR the V58.69 has one specific coding requirement. It must be a secondary diagnosis. The patinent’s reason for being on the medication must be the primary Dx. Therefore, you would code the Rheumathoid diagnosis as primary, V58.69 as second and the procedures would have the diagnosis pointer as “2” pointing to the V code.

Here is a screen shot of EyeCOR showing this:
HighRiskMeds1.jpg
Notice the information in green.
Remember: This screen shot is for California. Not all states support the same procedures.

Finally, back to Palquenil. You would use the V58.69 if the patient does not have Toxic Maculopathy of Retina. If the patient does have Toxic Maculopathy you would then code 362.55 Toxic Maculopathy of Retina.

[Robert Rebello]

Bob, (or anyone else care to comment). I sent this email to a few friends for comment and as usual, the coding and billing debate continues. These are a few responses from 3 OD's.


"If you use Eyecor program as I do, you can look up most medications and check for high risk ophthalmic manifestations of most common meds. Take Lipitor. as an example. Under potential severe complications are listed (amongst others) intraretinal hemorrhages and glaucoma. Bob says you can then use V58.69 as a secondary dx and procede with the approved tests allowed like VF and photos, and color vision. As you know Eyecor is medicare specific for our area. As I never have had a V58.69 denied I believe what he says. What a potential windfall for our practice. .


Others disagree about doing these as routine tests and billing them unless you saw something that would warrant the additional testing. Some feel the these tests are diagnostic and should be done as medicare approves them to be done to help determine if a problem exists.

**Just being on lipitor is not enough to warrant a VF. Now, IF you see intraretinal hemes, then go for it. Have a blast and get paid for what you are worth. However, to do it just because it is covered I think sets you up for some recoupment down the road when audited.

***OK. but when you have a plaquenil patient don't you do VF and photos? I do, even without seeing changes on ophthalmoscopy.

****I retort two things:
there is a standard on doing vf tests on Plaquenil patients. Such a standard does NOT exist on Lipitor. Remember, your documentation and treatment must be consistent with that of your local area peers.

*****We'd have to look at the LCD regarding V58.69 to better determine the risk of billing tests for every drug that has potential for severe ocular adverse effects. There are also AAO guidelines for Plaquenil, but not Lipitor as far as I know of. Much like malpractice, if the testing is usual and customary for most practitioners in the speciality, it would probably fly, but the LCD is still the best guide. An audit would be generated if the profile for one's office if it is substantially different form others in the area.


A good point...we can't bill photos in most cases unless there is something to document other than a normal state. Confusing the issue is that historically we have been able to bill photos for Plaquenil screening without disease being evident.

What say you Bob?

Here is the purpose of being allowed to perform certain procedures when the patient is on High Risk medications.

The statement was “Just being on lipitor is not enough to warrant a VF. Now, IF you see intraretinal hemes, then go for it.”

What is being missed is that the Diagnosis code is “On Long term or current use of High Risk Medication.” Being on the High Risk med is the diagnosis - not that they have a problem.

I believe the confusion stems from the fact you normally cannot do procedures simply to find something. However, in this case, the something allowing the procedures is the fact the patient is on the High Risk medication. That is the diagnosis.

If they actually have a problem (i.e., intraretinal hemes) then you code the Dx for that problem. The reason for allowing the procedures is to determine if there is a problem.

I hope this clears up the question.

[Robert Rebello]

Bob - is diabetes alone a justification for fundus photos? (250.00) - if the patient tells you their Blood sugar is poorly controlled , is that enough justificiation for fundus photos (250.02) If not - then how do the telemedicine schemes work? I am referriing to where a fundus camera is put into a internal medicine office and they take a photo and the photo is sent to a reading center. what justificiation does this scheme use for billling? Thanks for a good lecture? jim levinson, O.D.

Diabetes
This is another example of it depends on the state you are in. For Diabetes without complications:
- Some states allow exams (typically only 992xx E/M not 92xxx Ophthalmic exams).
- Some states allow exams plus certain procedures. For regions that do allow procedures, the most common is Fundus. However, some do not allow Fundus but allow Extended Ophthalmoscopy.
- Some states do not allow anything for diabetes (without complications). No exams nothing!

I realize there is much confusion about what you can bill from one region to another. This and the discussion about billing differences are two examples of the significant differences between regions. This is a very important part of what EyeCOR provides. When you look up 250.0x, EyeCOR will show you specifically what exams and/or procedures you can perform.

Remote Imaging
The Tele-medicine or “Remote Imaging” procedures are the most misunderstood procedures I have seen in a long time. These are:

92227 - Remote Imaging-Detection of Retinal Disease With Analysis/Report Under Physician Supervision
92228 - Remote Imaging-Monitoring/Management of Active Retinal Disease With Physician Review

I see doctors who bill both this code and the 92250 Fundus code.

The 92227(8) codes are “This code is only used and billed by the Physician interpreting the image, who is at a remote location from where the image was taken.” In your example, the location that took the photo would bill 92250 – TC. That is the “Technical Compontent” for simply taking the photo. The remote location actually has two options. One would be to bill 92250 – 26 (The professional compontent. Reading and doing the Interpretatition Report). The other alternative would be to bill the 92227/8, but only if the doctor was at a remote location.

Now lets look at the numbers:
The professional component varies (by region) between 33% and 40% of the full reimbursement. For one example here are the reimbursement numbers:
92250 Full Reimbursement – $69.14
92250 – 26 Professional - $22.48
92227 Remote for Detection - $10.68
92228 Remote for Management - $28.40

Therefore, if someone is analyzing the image remotely Looking for something, they are better off charging the 92250 – 26. It reimburses higher. Only if the physician is managing a patient with a known diagnosis, then they can use 92228 which reimburses higher.

[Robert Rebello]

I have gone through this thread several times. I believe I have answered all the questions. If I missed anything please re-post the question.

[Jim Levinson]

Diabetes
This is another example of it depends on the state you are in. For Diabetes without complications:
- Some states allow exams (typically only 992xx E/M not 92xxx Ophthalmic exams).
- Some states allow exams plus certain procedures. For regions that do allow procedures, the most common is Fundus. However, some do not allow Fundus but allow Extended Ophthalmoscopy.
- Some states do not allow anything for diabetes (without complications). No exams nothing!

I realize there is much confusion about what you can bill from one region to another. This and the discussion about billing differences are two examples of the significant differences between regions. This is a very important part of what EyeCOR provides. When you look up 250.0x, EyeCOR will show you specifically what exams and/or procedures you can perform.

Remote Imaging
The Tele-medicine or “Remote Imaging” procedures are the most misunderstood procedures I have seen in a long time. These are:

92227 - Remote Imaging-Detection of Retinal Disease With Analysis/Report Under Physician Supervision
92228 - Remote Imaging-Monitoring/Management of Active Retinal Disease With Physician Review

I see doctors who bill both this code and the 92250 Fundus code.

The 92227(8) codes are “This code is only used and billed by the Physician interpreting the image, who is at a remote location from where the image was taken.” In your example, the location that took the photo would bill 92250 – TC. That is the “Technical Compontent” for simply taking the photo. The remote location actually has two options. One would be to bill 92250 – 26 (The professional compontent. Reading and doing the Interpretatition Report). The other alternative would be to bill the 92227/8, but only if the doctor was at a remote location.

Now lets look at the numbers:
The professional component varies (by region) between 33% and 40% of the full reimbursement. For one example here are the reimbursement numbers:
92250 Full Reimbursement – $69.14
92250 – 26 Professional - $22.48
92227 Remote for Detection - $10.68
92228 Remote for Management - $28.40

Therefore, if someone is analyzing the image remotely Looking for something, they are better off charging the 92250 – 26. It reimburses higher. Only if the physician is managing a patient with a known diagnosis, then they can use 92228 which reimburses higher.

Bob- thanks for your reply- I stll do not understand the justifications for remote imaging. It seems that these systems fish for pathology. If the dx is plain type 11 diabetes what would be the justification for taking a remote image and sending it out for interpetation?

jim levinson, O.D.

[Joseph Lebow]

Bob, There is confusion among some of us on the Interpretation and Report. It needs to be separate from the comprehensive exam, but does it need to be in a separate location? Some have told me that it can't be in the patients chart and is filed some place else. Another told me that he has a different computer that keeps the I & R's away from his EMR. Is this correct? Or do you just put the I & R on a separate sheet of paper but keep it in the patients chart folder. Or with an EMR can the I & R be on it's own and listed among the other office visits, not part of another exam. Thanks Joseph Lebow

[AdminWolf]

an anonymous poster asks...

If a pt is pre-diabetic, is that a medical or wellness exam?
If a pt can't see 20/20 and you want to check for macular issues with an OCT but don't find anything, how do you bill the OCT?