Third Party Newsletter (SEE PAGE SIX) MEDICARE SUPERVISION REQUIREMENTS 4

March 2003 Deadline April 14, 2003 Volume 3 Issue 3 HIPAA Privacy We’re At the Finish Line...

FOUND AT THE NOA 3RD PARTY WEB SITE

¨ NOA HIPAA Manual (NOA sim- plification of AOA Manual) · In Adobe PDF Format · In MS Word Format ¨ NOA HIPAA Manual Instruc-

tions · In Adobe PDF Format · In MS Word Format ¨ HIPAA Signs for your office Dr. Quack is confident that you and your ¨ NOA PowerPoint Presentation staff are now prepared for HIPAA Privacy. given in February by Dr. Quack With all of the HIPAA hoopla in the last six ¨ AOA HIPAA Privacy Manual months it would be hard to be otherwise. (All 160 pages with worksheets, But, just in case you would like to review charts, and forms) our NOA HIPAA Privacy resources to confirm your preparedness, you can find ¨ Office of Civil Rights HIPAA everything you need on the special HIPAA Guidance Document (123 page of the 3rd Party section of our NOA pages) released 12/02 web site (www.noaonline.org). ¨ HIPAA Privacy Rules ASSOCIATION (Finalized) (Updated 10/02) Last Minute Questions? Dr. Quack’s ¨ Covered Entity Flow Sheet (Are query line (402-466-7470) is always open. you covered by HIPAA?) And he’ll do his best to help you cross the finish line on time!

Ignore Old HIPAA “Consent” Forms “Consent” No Longer Needed to use PHI for Treatment, Payment or Health Care Operations

The original 200l (now outdated) version of HIPAA final rules as published by the Bush administration privacy required each patient to sign a “consent” in October of 2002 deleted this requirement, thus form allowing the practitioner to use PHI for treat- eliminating the need to use the “consent” form. Un- ment, payment, and health care operations. If the fortunately, the form is still being advertised. Ignore patient declined to sign the consent form the practi- the form...it’s no longer needed. tioner could refuse to see the patient. However, the

Inside this issue:

PACHYMETRY LMRP DRAFT 2 SPECIAL NOTE: NEBRASKA OPTOMETRIC NEW BCBS POST-OP POLICY COMING UP 3 Þ DMERC MANUAL NOW ONLY AVAILABLE ON-LINE MEDICARE REIMBURSEMENT FOR JAN—FEB 2003 3

Third Party Newsletter (SEE PAGE SIX) MEDICARE SUPERVISION REQUIREMENTS 4

EXTENDED OPHTHALMOSCOPY 5

March 2003 Good News : Medicare Drafts LMRP for Pachymetry

You will be pleased to find pachymetry listed at the Medi- other plastic surgery for unacceptable cosmetic appearance, plus the care website under draft LMRPs (Local Medical Review modifier GY. In the case of a statutorily excluded service, the Medicare Policies). Despite significant restrictions for reimbursement limiting charge does not apply.

(of about $84 per patient), the LMRP is a positive step in Modifier KX may be used with code 0025T when the provider believes patient care when considering the results of the Ocular Hy- additional information might result in payment for the service under pertension Study. The Draft LMRP can be found at: circumstances in which it would usually be denied. An example

HTTP://WWW.KANSASMEDICARE.COM/PART_B/LMRP/DRAFTS/BDRAFT_PACHYMETRY_CORNEA.HTM would be an ophthalmologist or optometrist who examines a patient who previously has been cared for by another eye care provider. The patient Some highly abbreviated excerpts from the Draft follow. states they have glaucoma, they have had corneal pachymetry, and they are taking eye drops to treat glaucoma. The second ophthalmologist or Indications and Limitations optometrist questions the diagnosis of glaucoma. They make a reason- Corneal thickness measured by corneal pachymetry affects clinical able effort to obtain the existing pachymetry record from the former oph- decisions or diagnostic tests in the following: thalmologist or optometrist. However, they do not receive the measure- · measurement of intraocular pressure; ment. The second ophthalmologist or optometrist documents this in the · measurement of physiologic function of corneal endothelial patient’s record, performs the diagnostic test and bills for the service with cells; the KX modifier attached. A second example might be when corneal · measurement of corneal thickness in preparation for refrac- pachymetry is performed in order to aid in determining if a penetrating tive surgery. keratoplasty is indicated. If it has been less than one year since a previ- Code 0025T will be considered bilateral and assigned the same relative ous corneal pachymetry CPT level III code 0025T may be billed with the value units (RVUs) as code 76516 ophthalmic biometry by ultrasound. modifier KX. [Ed. Note: about $84 in NE]. When corneal pachymetry is allowed once per year begin counting the Corneal pachymetry will always be denied when it is used in clinical month following the previous corneal pachymetry. Eleven months after decision-making associated with refractive surgery. Refractive surgery the month following the prior corneal pachymetry, another corneal pachy- is a statutorily excluded service [Social Security Act 1861a7-Cosmetic metry will be allowed. surgery].

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY When there is not a scientifically demonstrated effect upon medical management of a disease, corneal pachymetry will be denied. For ex- 364.53 PIGMENTARY IRIS DEGENERATION ample, when the diagnosis of glaucoma has been established, corneal 364.77 RECESSION OF CHAMBER ANGLE 365.00 BORDERLINE GLAUCOMA [GLAUCOMA SUSPECT]; PREGLAUCOMA, UNSPECI- pachymetry will not add medically necessary information to the clinical FIED management decisions. A second example is prior to cataract surgery 365.01 BORDERLINE GLAUCOMA [GLAUCOMA SUSPECT]; OPEN ANGLE WITH BOR- DERLINE FINDINGS there is no proof measuring endothelial cell number or function, i.e., 365.02 BORDERLINE GLAUCOMA [GLAUCOMA SUSPECT]; ANATOMICAL NARROW corneal pachymetry improves patient outcome by influencing the type ANGLE of cataract surgery technique, extracapular expression or phacoemulsi- 365.03 BORDERLINE GLAUCOMA [GLAUCOMA SUSPECT]; STEROID RESPONDERS 365.04 BORDERLINE GLAUCOMA [GLAUCOMA SUSPECT]; OCULAR HYPERTENSION fication. Corneal clarity and endothelial cell function over the long-term 366.11 PSEUDOEXFOLIATION OF LENS CAPSULE is the same following either technique. The corneal pachymetry is not 371.20 CORNEAL EDEMA, UNSPECIFIED medically necessary to make a clinical decision. However, if there was 371.21 IDIOPATHIC CORNEAL EDEMA 371.22 SECONDARY CORNEAL EDEMA evidence of corneal endothelial dysfunction prior to cataract surgery 371.23 BULLOUS KERATOPATHY and the purpose of corneal pachymetry was to aid in the decision 371.57 ENDOTHELIAL CORNEAL DYSTROPHY COVERAGE IS FURTHER RESTRICTED TO ONLY FUCH’S ENDOTHELIAL DYSTROPHY WITHIN THIS DIAGNOSIS CODE. whether to perform a combined corneal transplant plus cataract surgery 371.58 OTHER POSTERIOR CORNEAL DYSTROPHIES or cataract surgery alone, corneal pachymetry may be medically neces- 996.51 MECHANICAL COMPLICATIONS OF OTHER SPECIFIED PROSTHETIC DEVICE, sary. IMPLANT, AND GRAFT; DUE TO CORNEAL GRAFT

Coding Guidelines Correct Procedural Terminology Code Level III 0025T “Corneal Pachymetry” will be assigned the same relative value units (RVUs) as procedure code 76516, ophthalmic biometry by ultrasound. Corneal pachymetry code 0025T will be considered a bilateral service. One unit Documentation of service will be paid for measurement on either both eyes or one eye. Requirements Modifier GZ should be used with code 0025T when the provider believes the service will be denied due to [lack of] medical necessity. The medical record must An example would be if the provider wished to measure corneal thick- contain a specific reference ness in a patient with a diagnosis of glaucoma. In this case, corneal to the corneal pachymetry pachymetry would not be medically necessary to make a decision to measurement and this treat glaucoma. measurement’s effect upon the clinical decision-making Modifier GY should be used with code 0025T when the provider be- process. This is the interpre- lieves the service will not be paid because of statutory exclusion. An tation of the report. example would be corneal pachymetry performed in preparation for refractive surgery. This may be submitted using ICD-9 code V50.1,

Page 2 March 2003 THIRD PARTY NEWSLETTER More Good News : BCBS Drafts New Pre- & Post-op Care Policy

The following information sure accurate usage of the above modifiers. regarding post-op coding was included in the Febru- For claims processed ary 2003 issue of the Blue on and after May 1, 2003

Cross—Blue Shield Update BCBSNE will discontinue the 3 days prior/14 days after pre- newsletter. and post-operative global period; and instead, implement a BCBSNE announced global surgical period similar to CMS. Refer to your CPT Sur- adoption of a pre-operative gery Guidelines Chart to determine which surgical procedures and post-operative medical include pre- and post-operative care. Note: These changes apply to all lines of business. All surgical procedures policy similar to Centers for must be billed prior to the post-operative services or Medicare and Medicaid along with the post-operative services. In the event an- Services (CMS). This other surgical procedure is performed during the post- change involves two operative period of an initial procedure, a new post- phases. operative period will apply. When Itinerant surgery is in-

volved, BCBSNE will continue to reimburse the surgeon the Beginning with claims processed lesser of the surgeon’s charge or 90 percent of the negotiated on and after February 1, 2003 fee schedule. The assistant surgeon, when applicable, will continue to receive the lesser of his/her charge or 20 percent BCBSNE will recognize and separately reimburse for of the negotiated fee schedule and may also be reimbursed Evaluation and Management (E&M) services performed the lesser of their charge or 10 percent of the negotiated rate within the pre-operative and/or post-operative period when for all uncomplicated pre- and post operative care. billed appropriately with the following modifier(s): -24 Indicates than an unrelated E&M service was per- BCBSNE will honor this arrangement as long as the appropri- formed by the same physician during a post-operative ate modifiers are utilized (-54, -55 & -56). period -25 Indicates that the E&M service performed on the BCBSNE plans to publish a follow-up article outlining common same day of the procedure or surgery is separately iden- Q and A’s in April. tifiable -57 Indicates that the E&M service performed on the day The BCBS Update newsletter can be found at: before or the day of surgery resulted in the initial decision HTTP://WWW.BCBSNEPROVIDER.COM/PROVIDERLIBRARY/_PDF/UPDATENEWSLETTER/2003_02.PDF for surgery BCBSNE may periodically request medical records to en-

Good News & Bad News : Medicare Reimbursement for Jan – Feb 2003

Payment Correction of accounts when the “automatic adjustment” takes place after July 1st. Just picture all of the less-than-one-dollar adjustments your office may Medicare Physician Services have for Jan-Feb 2003 patients billed after March 1st. Ugh. Provided in January and February 2003 What to do? Medicare encourages providers and suppliers to access Medicare reimbursement for the first part of 2003 is somewhat the Local Medicare Website at convoluted. Here are the facts at the moment as Dr. Quack under- HTTP://WWW.KANSASMEDICARE.COM/PART_B/PART_B_REIMBURSE.HTM stands them : 1) The 2003 Medicare Fee Schedule rates were not actually for the 2003 Medicare effective until March 1, 2003. (Bad news.) Physician Fee Schedule 2) The 2003 Medicare fee schedule is generally greater than the payment amounts that 2002 fee schedule. (Good news.) went into effect on March 3) Claims with January and February 2003 dates of service that 1, 2003. Those providers are processed after March 1st will erroneously be paid at the who do not have Web ac- 2003 rates. (Bad news.) cess may contact the 4) These claims will be automatically adjusted after July 1, Medicare Part B Reim- 2003 to pay correctly at the 2002 rates. (Bad news.) bursement department at 5) Physicians/practitioners will not need to take any further (866) 839-2440, option 3, action to receive the adjustment payments. (Good news.) to obtain a hardcopy of the new 2003 Locality Fee What, exactly, does all this mean to you and your office? Your Schedule booklet. insurance staff - bookkeeping department may have a royal mess on their hands trying to correctly modify patient payments and

VOLUME 3 ISSUE 3 March 2003 Page 3 PHYSICIAN SUPERVISION OF DIAGNOSTIC PROCEDURES AS REQUIRED BY MEDICARE

2003 MPFSDB Payment Policy Indicator Manual

Section 410.32(b) of the Code of Federal Regulations, as adopted in the Medicare physician fee schedule final rule of Code Level October 31, 1997, requires that diagnostic tests covered under §1861(s)(3) of the Social Security Act and payable under the 92060TC 01 physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an 92065TC 01 individual meeting the definition of a ”physician” (§1861(r) of the Social Security Act) to be considered reasonable and nec- 92081TC 01 essary and, therefore, covered under Medicare. The regulation defines these levels of physician supervision for diagnostic 92082TC 01 tests as follows: 92083TC 01 General supervision means the procedure is furnished under the physician’s overall direction and control, but 92135TC 01 the physician’s presence is not required during the per- 92235TC 02 formance of the procedure. Under general supervision, the training of the non-physician personnel who actually 92240TC 02 performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the con- 92250TC 01 tinuing responsibility of the physician. 92265TC 03 Direct supervision in the office setting means the physician must be present in the office suite and immedi- 92270 01 ately available to furnish assistance and direction 92270TC 01 throughout the performance of the procedure. It does not mean that the physician must be present in the room 92275 01 when the procedure is performed. 92275TC 01 Personal supervision means a physician must be in attendance in the room during the performance of the 92283TC 01 procedure. 92284TC 01 92285 01 Level Description 92285TC 01 1 Procedure must be performed under the general supervision of a physician. 92286 01 92286TC 01 2 Procedure must be performed under the direct supervision of a physician. Dr. Quack Note: TC refers to the technical compo- nent of the procedure only. 3 Procedure must be performed under the personal supervision of a physician.

SOURCE:: HTTP://WWW.KANSASMEDICARE.COM/PART_B/MANUALS/MPFSDB/2003/03_SUPERVISION_DIAG_PROCEDURES.PDF

Page 4 March 2003 THIRD PARTY NEWSLETTER Dr. Quentin Quack’s Queries and Questionable Quotes

~~~~~~~~~~~~~~~~~~~~~~~~~~ Third Party Questions from NOA Doctors and Staff ~~~~~~~~~~~~~~~~~~~~~~~~~~ Dr. Quentin Quack 92225—Extended Ophthalmoscopy

Dear Dr. Quack, of glaucoma (ICD-9 codes 365.00-365.82) must in- drawing should provide sufficient detail as to the extent What are the requirements for coding 92225 clude the following: of a retinal detachment, the location of retinal holes in extended ophthalmoscopy? When is it ap- * a detailed colored drawing of the optic nerve relation to the macula, equator, ora serrata, and major propriate to use that code? * documentation of cupping, disk rim, and shape retinal vessels. It should clearly illustrate the anterior/ * documentation of any surrounding pathology around posterior position as well as the clock hour location of Dr Quack’s Quote: the optic nerve tears. Areas of traction, vitreous opacities, hemor- * documentation of the cup to disk ratio rhage, etc. should all be drawn and clearly labeled to Extended ophthalmoscopy, 92225, is de- Drawing dimensions should be of an adequate size to facilitate follow-up, referral to another physician, or fined in CPT-2003 as follows: allow ease in interpretation. proposed surgical treatment of the patient. The exact

92225 Ophthalmoscopy, extended, Covered ICD-9-CM Codes: Find list at size of the drawing is not as important as the informa- with retinal drawing (e.g., for retinal HTTP://WWW.LMRP.NET/LMRP/CARRIER/8/00824/ tion in the form of detail and relationships of ocular EXTENDEDOPHTHALMOSCOPY.HTM structures that it conveys. However, in general it detachment, melanoma), with interpre- LMRP: BCBS of Arkansas should be at least 5 cm in diameter to illustrate suffi- tation and report; initial cient detail. The use of colors is helpful, but not man-

By the examples given it is obvious that LMRP Description: Extended ophthalmoscopy is a datory as long as there is proper labeling. A brief ver- detailed fundus examination that goes beyond the bal interpretation of the findings is also required. 92225 is significantly more than a routine scope of the usual retinal exam which is included as a Other instances that might be appropriate for extended dilated fundus examination. Rather, this part of the comprehensive and intermediate eye ex- ophthalmoscopy, when photography is not available, code is to be used to describe and document aminations. It should include a detailed drawing and would be drawing retinal tumors with sufficient detail a serious diagnosis such as retinal detach- interpretation of findings. so as to show their relationship to retinal blood vessels ment or melanoma with a detailed retinal The procedure is performed with an instrument to and size relative to the optic nerve and with estimation drawing. allow inspection of the interior of the eye, particularly of elevation off the retinal surface. the retina and associated structures, with the pupil Where can a provider get further informa- The extended ophthalmology codes could also poten- dilated, for the purpose of detecting and evaluating eye tion on how and when to code 92225? Al- tially apply to glaucoma diagnoses when disc photog- disorders and manifestations such as systemic dis- though our own Medicare carrier has not raphy is not available and a large detailed drawing of a ease. promulgated a “Local Medical Review Pol- damaged nerve head is necessary to establish the icy” for extended ophthalmoscopy, other Indications and Limitations of Coverage and/ amount of nerve fiber loss from the disease process. In Medicare carriers have done so. These or Medical Necessity: Ophthalmoscopy, extended, this case there should be a careful drawing of the major disc vessels, their relationship to the cup, depic- LMRPs should give us reasonable guide- (CPT code 92225) is considered to be reasonable and necessary for the evaluation of neoplasms of the retina tion of cup depth and color estimation (i.e., labile pal- lines in coding extended ophthalmoscopy as lor). Again detail of the drawing that exceeds a simple generally accepted in other locales. Ex- and choroid (benign and malignant), retinal hemor- rhages, ischemia, exudative detachment, and retinal verbal description (0.6 vertical cup) is necessary to cerpts from two of them follow. (Their web defects without detachment. It is also reasonable and justify the use of this code. A simple drawing of the addresses are supplied so you may read necessary for other ocular disorders including sudden cup/disc ratio is not sufficient, nor is the use of a tem- them in their entirety.) plate with predrawn retinal vessels. and transient visual loss, intraocular foreign bodies, disorders of the vitreous body, diabetic retinopathy, LMRP: Colorado, North Dakota, Covered ICD-9-CM Codes: Find list at back ground retinopathy with retinal vascular changes, HTTP://WWW.LMRP.NET/LMRP/CARRIER/6/00522/ South Dakota and Wyoming and glaucoma when the patient's medical record EXTENDEDOPHTHALMOSCOPY.HTM meets the documentation requirements set forth in the Reasons for Non-Coverage: Routine ophthalmo- policy. scopy is a part of general and special ophthalmologic services whenever indicated. It is a non-itemized ser- CPT code 92226, subsequent extended ophthalmo- vice and is not reported separately. Medicare does not scopy and drawing would be indicated only if there reimburse for routine screening procedures. ICD-9 were changes such as, in the fluid in a retinal detach- codes other than those listed in the Covered ICD-9 ment, finding new holes, or growth of a tumor. Codes@ section of this policy will not be covered. For consideration of CPT code 92225, there must be Coding Requirements: The appropriate ICD-9- significant retinal pathology that justifies this detailed CM code for the covered procedure must be submitted examination. The medical records should clearly docu- as the line diagnosis on the claim. ment the medical necessity for the exam.

Documentation Requirements: Medical record The detailed retinal drawing is very important to docu- documentation must contain the symptoms and physi- mentation of the proper use of this code. The retinal cal findings to substantiate the medical necessity and drawing should convey the nature of the lesion based appropriateness of this procedure. upon internationally recognized retinal drawing tech- Documentation in the medical record for the diagnosis niques and include appropriate detail. As example, a

VOLUME 3 ISSUE 3 March 2003 Page 5 NEBRASKA OPTOMETRIC ASSOCIATION

201 N. 8TH Street, Suite 400 P.O. Box 81706 Lincoln, NE 68501

DMERC MANUAL UPDATES ONLY AVAILABLE ON WEB

The quarterly update ot the DMERC Region D Supplier Manual is usually mailed with the DMERDC Dialogue; however, the supplier manual updates will not be mailed and will only be available on the CIGNA Medi- care Web site.

The Spring 2003 DMERC Region D Supplier Manual updates can be ac- cessed and downloaded from the CIGNA Medicare Web Site at www.cignamedicare.com/dmerc/dmsm/index.html

IMPORTANT

This issue of the Third Party Newsletter has been reviewed by (please check your box): 5 The Doctor 5The Office Manager 5The Insurance Staff

Dr. Quentin Quack’s Queries...continued

up as he noticed that the rope by which he was suspended was old and frayed. With a trembling voice ccasionally Dr. Quack’s fax O he asked the monk who was going machine or email contains a ques- tion or story that is interesting, but up with him how often they changed may not pertain directly to third the rope. The monk thought for a party care. Dr. Quack feels that he moment and answered brusquely, should share some of these humor- "Whenever it breaks." ous thoughts. Yousay WHAT?

The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed There once was a monastery in Schneider, O.D., Third Party Consultant.

Europe perched high on a cliff sev- Nebraska Optometric Association eral hundred feet in the air. The 201 North Eighth Street, Suite 400 P.O. Box 81706 (68501) only way to reach the monastery Lincoln, Nebraska 68508 was to hold onto a rope which was Phone: 402-474-7716 Fax: 402-476-6547 then pulled to the top by several Email: [email protected] monks who pulled and tugged with On one occasion a tourist got ex- Ed’s Fax & Voicemail: 402-466-7470 all their strength. Obviously the trip Ed’s Email Address: [email protected] up the steep cliff was terrifying. ceedingly nervous about half-way Ed’s Emergency Pager: 402-790-7971

VOLUME 3 ISSUE 3 March 2003 Page 6