Co-managing cataract surgery? Avoid these 5 billing mistakes

Plus, other things to consider when investigating co-management

FFor many eye care providers, co-managing an eye surgery patient presents several distinct advantages. By sharing the responsibility, authority, and accountability for a patient, the ophthalmologist can perform a surgical procedure while the optometrist can manage the patient after the surgical procedure.

Working in this sort of cooperative fashion to provide pre- and post-operative cataract surgery care can provide valuable benefits to patients and many great opportunities for eye care practices.

Though by no means a new area of practice, cataract surgery co-management has been gaining in popularity as eye care providers seek to offer enhanced services and expand their scope of work. Co-management for cataract surgery care can also facilitate on-the-spot referrals and more efficient patient care. In this mode of practice, patients receive enhanced benefits and services because they get easier access to high-quality eye care — and, of course, when patients, win, doctors win, too.

Co-management for cataract surgery is become more popular – Here are some reasons why

Co-management is becoming a popular model of service delivery in rural communities, giving smaller practices with more limited scope and abilities access to the most advanced levels of care. Patients may benefit from not having to drive to a big city or intimidating medical center for care, and also are encouraged to seek care locally when the might otherwise skip a visit due to the inconvenience of travel.

Co-managing as a type of collaborative care for cataract surgery can be beneficial for all parties involved:

  • The patient can receive follow up care from his or her optometrist (with whom the patient may be more comfortable due to a pre-existing relationship).
  • Co-management could open up a new revenue stream for the optometrist who may otherwise lose patients to practices with broader abilities, more advanced equipment, and better name recognition.
  • The optometrist gets to see a greater variety of patients and conditions in addition to the routine eye care he or she may be used to providing, which helps to break the monotony of day to day care and offers enhanced opportunities for professional advancement, as well as the opportunity to connect professionally with a new set of partners.
  • The ophthalmologist no longer needs to spend time on follow-up care and routine eye exams, freeing up additional time for more surgeries in addition to growing his or her referral network.

Billing issues that co-management parties should be aware of before getting to work

Co-management in a cataract surgery setting, however, can present a new set of issues that all parties involved need to work through, and special attention needs to be paid to billing. You, your office, and in particular your billing staff, should be aware of these possible billing challenges before you decide to pursue this type of care arrangement.

Get to know the following five co-management caveats that could impact your eye care practice. Knowing and avoiding these five common co-management billing errors will prevent denials and keep your revenue cycle rolling along!

Look out for these five common co-management billing errors that lead to denials:

  1. Using the patient’s post-op visit date as the date of service on the claim form, when it should actually be the surgery date. The claims for surgical care and post-op care must both list the same surgical date of service.
  2. Not including the dates of assuming and relinquishing care on the claim form when physicians share postoperative care. Ensure you get reimbursed for each day you provide care during the global period by listing the date range in the appropriate field – Provider must report the date when post op care assumed from another provider including the date post-op care began and ended along with the number of post-operative care days provided in the narrative field on electronic claim, or item 19 on the CMS 1500 claim form. This will facilitate processing of the claim and reduce unnecessary rejections.
  3. Using an E/M or eye code to bill for the post-surgical visit instead of the surgical procedure code (like 66984 for extracapsular cataract removal with insertion of intraocular lens prosthesis)
    Usage of modifiers – Modifier 54 (surgical care only) is appropriate to be utilized by operating surgeon on cataract surgery claim; however, modifier 55 (Postoperative management only) is appended on postop co – management care claim with cataract surgery CPTs i.e., 66984 apart from anatomical modifier e.g. RT, LT, and 50
  4. Failing to bill separately when a new condition appears that is unrelated to the surgery or conversely, billing separately for a new condition that actually is surgically related.
  5. Routinely billing for co-management on the date care was assumed. You can’t bill for co-management until at least one service has been provided to the patient. However, you don’t have to wait until the end of the global period to submit the claim.For medical billing coders, codes to be aware of in cataract surgery co-management situations include:
    • Office visit: 99203, 99204, 99214, 92004, and 92014
    • Initial office visit: 99202, 99203, 99204, 99205, 92002 & 92004
    • Initial refraction: 92015
    • Post-op refraction: 92015
    • Special endothelial microscopy: 92286
    • Cataract surgery codes: 66982, 66984,
    • New cataract codes introduced in 2022: 66989, 66991

Common ICD-10 codes for the cataract family or care include:

  • H25.011 Cortical age-related cataract, right eye
  • H25.012 Cortical age-related cataract, left eye
  • H25.013 Cortical age-related cataract, bilateral
  • H25.019 Cortical age-related cataract, unspecified eye
  • H25.10 Age-related nuclear cataract, unspecified eye
  • H25.11 Age-related nuclear cataract, right eye
  • H25.12 Age-related nuclear cataract, left eye
  • H25.13 Age-related nuclear cataract, bilateral
  • H25.819 Combined forms of age-related cataract, unspecified eye
  • H25.89 Other age-related cataract
  • H21.221 Degeneration of ciliary body, right eye
  • H21.222 Degeneration of ciliary body, left eye
  • H21.261 Iris atrophy (essential) (progressive), right eye
  • H21.262 Iris atrophy (essential) (progressive), left eye
  • H21.81 Floppy iris syndrome
  • H21.89 Other specific disorders of iris and ciliary body
  • H21.9 Unspecified disorder of iris and ciliary body

Remember that cataract surgery is considered a major surgery with a 90-day post-op global period. The total global period, however, is 92 days, since it includes the day before the surgery and the day after the surgery. The 90-day global period is 20 percent of the allowable Medicare fee. You should figure out how many days you will provide care during the 90-day post-op global period to know what your fee will be. And, if the second eye has surgery performed on it after surgery for the first eye, remember that the global period fee is figured out using the same method.

Eye care providers should always charge for and collect fees for refraction during the global period as refraction is not usually covered by Medicare and the majority of other insurance plans. Remember that, when submitting your claim to Medicare, not all carriers require the same information. Know what yours does in order to save time and reduce requests for more or correct information.

Don’t forget about other aspects of co-management to be aware of

While billing may be top of mind for most co-managing parties, there are other aspects to be aware of before you get to work. Those include:

  • Make sure your visions are aligned: Sure, maybe co-management is a good idea from a dollars and sense perspective, but that does not necessarily mean that both parties have the same long-range goals in mind. Before finding a co-management partner, make sure you have honest conversations about money, personnel, and where you want you and your office to be next year and the year after that.
  • Understanding who does what: While a co-management agreement between two small practices may be simple, things can get more complicated when practices are bigger. Optometrists who serves as consultants to referring doctors of optometry and conduct assessments of patients may need more sophisticated plans and agreements to coordinate evaluation and treatment. For practice with multiple locations, and particularly when they operate in different states, managing care can be even more complicated.
  • Keep learning: While the growth in co-management is a positive development for both patients and practices, specialists need to work together to ensure high-quality patient care and dependable access to timely services. Openly sharing information on continuing education opportunities and maintaining clear lines of communication can ease worries and confusion.
  • Work on building trust among both parties: Co-management may not come naturally to every party involved, as some could see it as a hassle or even a partnership with a practice that otherwise is a competitor. To get the most out of this share relationship, parties should actively work to build and maintain trust, with the end result focused on better care for patients.

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