Correct Coding for Your Retina Practice

Want to audit-proof your retina practice’s revenue cycle? Correct coding is essential to the equation.

Start with These Correct Coding Basics

Make sure your coders and billers have mastered NCCI edit principles, Joy Woodke, COE, OCS advised practice administrators at AAO 2017. Your RCM team should be experts on modifiers, because that’s the top reason most retina practices see denials, she said.

Track global periods per procedure and per payer to create a handy reference tool for staff appending modifiers related to global periods, suggested Woodke, who is a practice administrator for Oregon Eye Consultants.

You also need to pay attention to global periods on a patient-by-patient basis, observes Torrey Kim, editor of Ophthalmology Coding Alert, pointing to a YAG and a subsequent lash epilation as an example. Retina patients are complicated, so that means they often require new, unrelated procedures while still in the global period for a previous procedure. Your retina practice will get its rightful reimbursement only if you append the correct modifiers when reporting these encounters.

ICD-10: Not Just About Medical says Jane T. Shuman, COT, COE, OCS, CMSS,  president and founder of Eyetechs Necessity

ICD-10 codes not only support the medical necessity of the procedures being billed at the time, but they also impact your practice revenue generally as MIPS and risk-based reimbursement ramp up, observes Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, chief compliance officer at Century Vision Global.

Many of the patients who visit your retina practice are very sick, and their treatment plans are therefore more difficult for providers to manage and the desired outcomes more difficult to achieve, Buckholtz explains. Make sure that your patients’ referring physicians have documented co-morbid conditions and that you code for them. Undercoding co-morbid conditions could negatively impact both your MIPS incentives and your CMS Physician Compare scores.

The importance of correct co-morbidity coding is one more reason it’s a good idea to assign your most experienced techs to new patient visits, observes says Jane T. Shuman, COT, COE, OCS, CMSS,  president and founder of Eyetechs.

Documentation for Diagnostic Testing Is More Important Than Ever

Outside auditors currently have diagnostic testing in their crosshairs. Auditors are closely scrutinizing documentation for medical necessity, as well as interpretation and report, Buckholtz notes. Simply pulling test results from your EMR does not satisfy requirements won’t audit-proof your retina practice, experts warn.

Let’s look at extended ophthalmoscopy (92225, 92226) as an example, Kim offers. “If the physician doesn’t find an anomaly, doesn’t draw and label any anomalies that are found, or if there isn’t an interpretation and report, you should not bill for the EO,” Kim says. “When billing 92226 (subsequent EO), be sure there have been changes in the patient’s signs, symptoms or condition, or your payer may deny the service as not medically necessary.”

EO is inherently unilateral, Kim reminds coders. If the physician performed EO on both eyes, you should append either modifier 50 or modifiers LT/RT, depending on the payer’s preference.

OCT is another auditing risk area for retina practices. In some practices, techs know that the doctor is going to want an OCT on a new patient, so they just go ahead and do it. It’s a compliance risk if the physician order for the OCT isn’t in in the medical record. “Standing orders” won’t pass muster with outside auditors, Buckholtz adds.

Auditors are also scrutinizing the frequency of diagnostic testing:

  • more than three annual fundus photography exams (92250)
  • more than five annual ophthalmoscopy exams (92225, 92226)
  • more than five annual fluorescein angiographies (92230, 92235) or indocyanine angiographies (92240)

Sweat the Small Stuff

As you attend to all the complex coding and billing issues for retina, don’t forget the basics as you coach your new techs and your scribes. “It may sound silly, but I’ve seen payers taking back a lot of money from providers because the wrong eye was mentioned in the documentation,” says Tricia Packer, CPC, CPMA, COPC, OCS, who serves on ECL’s practice optimization team and who previously administered a retina practice in North Carolina. For example, if the documentation mentions a retinal tear in the right eye during the exam, and subsequent laser procedure mentions the left eye, that claim will be denied or audited later.

Resource: Want to build your RCM team’s skills? AAO has created a new OCS exam especially for retina coders

Prior-Authorization Principles

Payers are setting more stringent prior-authorization requirements, which means your back office needs to be smarter about prior-authorizations than ever before.

Train your staff to check payer policies before each and every treatment, advises Packer, because what didn’t require prior-authorization last time may require prior-authorization today.

Most drug companies offer copay assistance programs or free drugs to patients who meet financial need requirements. Sign everyone up for programs like the Eylea program, just in case their insurance company lets them down, billing consultant Luretta Greeley, OCS told AAO 2018 attendees. If a patient hestiates to let you sign them up because they assume they’ll receive drug company solicitation they don’t want, explain to them that you’re working to protect them from having to pay $400 out-of-pocket per injection should insurance deny the claim. Having them enrolled ensures that your practice be able to collect reimbursement fromt the drug company in these instances.

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