CHANGE is Coming:
Compliance & Coding John A. McGreal Jr., O.D. Missouri Eye Associates
McGreal Educational Institute
Excellence in Optometric Education
John A. McGreal Jr., O.D.
McGreal Educational Institute
Missouri Eye Associates 11710 Old Ballas Rd. St. Louis, MO. 63141 314.569.2020 314.569.1596 FAX [email protected]
JAM 2014 Compliance Issues HIPAA Privacy & Security regulations change Medicare Updates for 2014 RAC Audits CERT Audits OIG Workplan ICD-10 conversion Healthcare Reform Basics Affordable Care Act Implementation
JAM
Medicare Part B Deductible
Deductible (Medicare Part B) – Will increase to $ in 2014 – thereafter increase by annual percentage increase in Part B expenditure
JAM 2012 New ICD-9 Glaucoma Coding Given great variability of cost of care & resource utilization among glaucoma patients, glaucoma care has been targeted for use of potential value -based modifiers in the future – ICD-9 and ICD-10 codes reflect this and will allow stratification of a patient population Developed by the American Glaucoma Society (AGS) workgroup, including Drs. Fellman & Mattox – Then enlisted comprehensive ophthalmologists, optometrists, and a few glaucoma specialists to evaluate and test for accuracy using real cases from Dr. J. Stein at University of Michigan JAM 2012 New ICD-9 Codes – Glaucoma Stages
When coding glaucoma subcategories 365.1-365.6 assign an additional code to identify specific stage of glaucoma (365.7) – 365.70 Glaucoma stage, unspecified – 365.71 Mild stage glaucoma – 365.72 Moderate stage glaucoma – 365.73 Severe stage glaucoma – 365.74 Indeterminate stage glaucoma Includes sequencing instructions to code first the glaucoma, by type
– Report new V19.11 history codes where appropriate JAM
Step One: Code by Type
Only the codes listed here require add-on staging codes – 365.10 Open angle glaucoma, unspecified – 365.11 Primary open angle glaucoma – 356.12 Low tension glaucoma – 365.13 Pigmentary glaucoma – 365.20 primary angle closure glaucoma, unspecified – 365.23 Chronic or primary angle closure glaucoma, unsp – 365.31 Steroid induced glaucoma – 365.52 Pseudoexfoliation glaucoma – 365.62 Glaucoma associated with ocular inflammations – 365.63 Glaucoma associated with vascular disorders – 365.65 Glaucoma associated with ocular trauma JAM Step Two: Add Stage Determine severity of glaucoma in worse eye – 365.71 Mild (disc abnormalities consistent w glaucoma but no VFD on SAP or Short wave-length doubling perimetry) – 365.72 Moderate stage (Disc abnormalities consistent w glaucoma and VFD in 1 hemifield, not w/in 5 degrees of fix) – 365.73 Severe stage (Disc abnormalities consistent w glaucoma VFDs in both hemifields, and/or loss w/in 5 degrees of fix in at least 1 hemifield) – 365.74 Indeterminate (VFs not performed yet, or patient incapable of VF testing or unreliable or uninterpretable VFs) – 365.70 Unspecified, stage not recorded in chart Compliance requires documentation of stage in medical record JAM Additional Glaucoma Code Changes 365.01 Open angle suspect, Low Risk (1-2 risk factors) 365.05 Open angle suspect, High Risk (3+ risk factors)
– Risk factors – family history, race, elevated IOP, disc appearance and thin central corneal thickness 365.02 Primary angle closure suspect (anatomical suspect, narrow angle) 365.06 Primary angle closure without glaucoma damage (defined as angle damage such as synechia or high IOP, but w/o optic nerve damage) 365.23 Chronic angle closure glaucoma (angle damage plus optic nerve damage) JAM Physician Value-Based Payment Modifier
CMS will adjust payment to some physicians based on quality & resource use beginning in 2015 and all physicians by 2017 – Now applies only to groups of 100 or more (originally 25) – Smaller groups (2-99) remain unaffected until 2017 3% payment penalty to hospitals began in 2012 for re-admission rates higher than national average – Heart failure – Pneumonia – Myocardial infarction
JAM Reduction in Diagnostic Testing
CMS will decrease payment by 20% of technical component of second and subsequent diagnostic tests furnished by same physician (or physicians in same group) to same patient on same day – Originally set at 25% – A diagnostic service refers to any diagnostic test that has a technical & professional component CMS indicated they will closely monitor practice changes to bypass multiple payment reductions
JAM Reduction in Diagnostic Testing
76510 92060 92228 92285 76511 92081 92235 92286
76512 92082 92240 76513 92083 92250 76514 92132 92270 76516 92133 92275 76519 92134 92283 92125 92136 92284
JAM HHS Announces HIPAA Audits The Office of Civil Rights will begin assessments of compliance with HIPAA Privacy & Security rules – Focus on providers and business associates Updated HIPAA Rules took effect September 23, 2013 for privacy & security Ensure patients receive electronic copy of PHI, on request Limit use or disclosure of PHI for marketing or fundraising, and advanced authorization required Prohibit sale of PHI for marketing w/o permission
JAM HHS Announces HIPAA Audits
Give patients who pay out of pocket for services the right to instruct doctors not to share information about treatment with insurance company Practitioners must have updated new business associates agreements documenting associates with access to PHI – Billing firms, clearinghouses, IT, data storage companies Security changes focus on increased lockdowns of electronic PHI, securing servers Implementation of new Notice of Privacy Practices JAM New Notice of Privacy Practices (NPP)
Add statement about opt out option for fundraising Add statement about HCP right to restrict PHI in
cash pay patients Add individual right to be notified of breach within 60 days, notification of HHS, individual and media Delete statement about reminders, health benefits etc Post new NPP prominently in office Paper copies of new NPP available for established patients to review New NPP given to each new patient JAM New Business Associates Agreements
New Business associates (BA) definitions and new business associates agreements (BAA) established
Liabilities and responsibilities substantially increased HCP not required to have BAA with subcontractors of BA Adds the word “maintains” PHI definition of BA – Substantial focus on data storage companies Requires ALL existing agreements be revised
JAM Civil Monetary Penalties (CMPs)
Unknowing violation $100-$50K $1.5M Reasonable cause $1000-$50K $1.5M
Willful neglect, corrected $10K-$50K $1.5M Willful neglect, uncorrected $50K $1.5M
Adoption of higher civil monetary penalties for violations of privacy or security
JAM New CPT Codes for 2014
99446 – interprofessional telephone/internet assessment and management service including a verbal & written report, 5-10 minutes of review 99447 – consultation as above, 11-20 minutes 99448 – consultation as above, 21-30 minutes 99449 – consultation as above, 31 minutes or more 66183 – Insertion of anterior segment aqueous drainage device, w/o extraocular reservoir, external approach
JAM CPT Category III Changes for 2014
0330T – digital interferometry of the lipid layer of tear film for dry eye diagnosis, unilateral or bilateral with interpretation & report – Do not report using 92285 external ocular photography 0333T – VEP, screening of visual acuity – Do not report 95930 VEP testing of CNS 0329T – monitoring of IOP for 24 hours, unilateral or bilateral with interpretation & report – Do not report 92100 serial tonometry 0341T – quantitative pupillometry, unilateral or bilateral with interpretation & report JAM
New 1500 Claim Form for 2014
CMS revised the 1500 form to more adequately support use of ICD-10CM code set
Revised form version 02/12 will replace current form which is version 08/05 CMS accepts revised version of form January 6, 2014 CMS will ONLY accept new version after April 1, 2014 Allows ability to indicate use of version 9 or 10 Expands diagnosis code list from 4 to 12! JAM PQRS Incentive Programs CMS continues incentive payments in 2014 – www.cms.gov/PQRI/15_MeasuresCodes.asp
Successful PQRS reporters earn 0.5% in 2014 Must report on at least 9 measures Report for full year (Jan1-Dec31, 2014) Not participating in PQRS 2014 will reduce Medicare payments by 2% in 2016 Not participating in EHR/MU in 2014 will reduce Medicare payments by 2% in 2016
JAM
PQRS Measures for 2014 Required to report on 9 measures (up from 3 in 2013) Required to report on 50% of applicable patients
Diabetes, AMD, and glaucoma are main measures – Select 2 other measures applicable to your practice base Measure #236 – HTN: controlling BP Measure #128 – Preventive care & screening: BMI Measure #111 – Preventitive care & screening: Pneumococcal vaccination in >65yo Measure #173 – Preventitive care & screening: Unhealthy alcohol use JAM
PQRS Measures for 2014 Measure #110 – Preventative care & screening: Influenza immunization
Measure #226 – Patient screened for tobacco use and received cessation counseling if identified as user Measure #130 – Current medications with name, dose, frequency, and route documented
JAM PQRS 2014
In 2015 a 1.5% PQRS payment penalty will be applied, in 2016 this increases to 2.0% – 2013 PQRS participation used to determine cuts in 2015 – Participation means attempting to report at least one PQRS measure between Jan 1 –Dec 31 2013 Glaucoma staging codes removed Measure 124: Health Information Technology eliminated CMS dramatically increases threshold to meet requirements – report 9 measures for incentive ‘14 JAM Measure 12: POAG Optic N. Evaluation
CPT category II Code: 2027F
Diagnosis codes 365.10 Open angle glaucoma – 365.11 Open angle glaucoma – 365.12 Low tension glaucoma – 365.15 Residual stage of open angle glaucoma – 365.70-365.74 Glaucoma stages codes Documentation tips – ON can be documented with a drawing, description, photograph or scan
Modifiers -1P, -8P JAM Measure 141: POAG Reduction of IOP by 15% or Documentation of Plan of Care IOP reduced by 15% from pre-intervention
– CPT category II Code: 3284F IOP reduced less than 15% from pre-intervention
– CPT category II Code: 3285F plus
– CPT category II Code: 0517F to document plan of care Recheck IOP, Rx change, additional testing, referral, plan to recheck Once per reporting period CPT Codes: 92002, 92004, 92014, 92012, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 JAM Measure 141: POAG Reduction of IOP by 15% or Documentation of Plan of Care
Diagnosis codes – 365.10 Open angle glaucoma – 365.11 Open angle glaucoma – 365.12 Low tension glaucoma – 365.15 Residual stage of open angle glaucoma – 365.7-365.74 Glaucoma Stage codes Modifiers -8P
JAM Measure 14: AMD Dilated Exam
CPT category II Code: 2019F Pts 50yrs+ with diagnosis AMD having DFE with documentation of presence or absence of macular thickening or hemorrhage AND level of severity (mild, moderate, severe) of AMD during one or more office visits w/in 12 mos, minimum of once per reporting period Diagnosis codes – 362.50 Macular degeneration, unspecified – 362.51 Non exudative senile macular degeneration (dry) – 362.52 Exudative senile macular degeneration (wet)
Modifiers -1P, -2P, -8P JAM Measure 140: AMD Counseling on Antioxidant Supplement Patients aged 50 and older with a diagnosis of AMD and/or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formulation for preventing progression of AMD CPT category II Code: 4177F Diagnosis codes – 362.50 Macular degeneration, unspecified – 362.51 Non exudative senile macular degeneration (dry) – 362.52 Exudative senile macular degeneration (wet) Modifiers -8P Note: If already receiving AREDS supplements, assumption is
counseling has already been performed JAM Measure 140: AMD Counseling on Antioxidant Supplement
CPT Codes: 92002, 92004, 92014, 92012, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
JAM Measure 117: Diabetes Mellitus Dilated Exam
CPT category II Code: – 2022F: dilated retinal exam by OD/OMD with interpretation documented and reviewed – 2024F: 7 standard field stereophotos with interpretation documented and reviewed – 2026F: eye imaging validated to match diagnosis from 7 standard field stereophotos with results documented and reviewed – 3072F: low risk for retinopathy (no evidence of retinopathy in prior year) Modifiers -8P
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 250.00 DM w/o ophthal manif, type II, not uncontrolled – 250.01 DM w/o complication, type I, not uncontrolled – 250.02 DM w ophthal complications, type II, uncontrolled – 250.03 DM w/o complication, type I, uncontrolled – 250.10 DM w ketoacidosis, type II not uncontrolled – 250.11 DM w ketoacidosis, type I, not uncontrolled – 250.12 DM w ketoacidosis, type II, uncontrolled – 250.13 DM w ketoacidosis, type I, uncontrolled
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 250.20 DM w hyperosmolarity, type II, not uncontrolled – 250.21 DM w hyperosmolarity, type I, not uncontrolled – 250.22 DM w hyperosmolarity, type II, uncontrolled – 250.23 DM w hyperosmolarity, type I, uncontrolled – 250.30 DM w coma, type II, not uncontrolled – 250.31 DM w coma, type I, not uncontrolled – 250.32 DM w coma, type II, uncontrolled – 250.33 DM w coma, type I, uncontrolled
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 250.40 DM w renal complic, type II, not uncontrolled – 250.41 DM w renal complic, type I, not uncontrolled – 250.42 DM w renal complic, type II, uncontrolled – 250.43 DM w renal complic, type I, uncontrolled – 250.50 DM w ophthal manif, type II, not uncontrolled – 250.51 DM w ophthal manif, type I, not uncontrolled – 250.52 DM w ophthal manif, type II, uncontrolled – 250.53 DM w ophthal manif, type I, uncontrolled
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 250.60 DM w neurol manif, type II, not uncontrolled – 250.61 DM w neurol manif, type I, not uncontrolled – 250.62 DM w neurol manif, type II, uncontrolled – 250.63 DM w neurol manif, type I, uncontrolled – 250.70 DM w periph circ disord, type II, not incontrolled – 250.71 DM w periph circ disord, type I, not uncontrolled – 250.72 DM w periph circ disord, type II, uncontrolled – 250.73 DM w periph circ disord, type I, uncontrolled
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 250.80 DM w other manif, type II, not uncontrolled – 250.81 DM w other manif, type I, not uncontrolled – 250.82 DM w other manif, type II, uncontrolled – 250.83 DM w other manif, type I, uncontrolled – 250.90 DM w unspec complic, type II, not uncontrolled – 250.91 DM w unspec complic, type I, not uncontrolled – 250.92 DM w unspec complic, type II, uncontrolled – 250.93 DM w unspec complic, type I, uncontrolled
JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 357.2 polyneuropathy in DM – 362.01 background diabetic retinopathy – 362.02 proliferative diabetic retinopathy – 362.03 nonproliferative dibetic retinopathy – 362.04 mild nonproliferative retinopathy – 362.05 moderate nonproliferative retinopathy – 362.06 sever nonproliferative diabetic retinoipathy – 362.07 diabetic macular edema – 566.41 diabetic cataract JAM Measure 117: Diabetes Mellitus Dilated Exam
Diagnosis Codes
– 648.00 DM unspecified as to episode or care or not applicable – 648.01 DM delivered, w or w/o mention of antipartum condition – 648.02 DM antepartum condition or complication – 648.04 DM postpartum condition or complication
JAM Measure 18: DM Documentation of Presence of ME & Level of Severity of Retinopathy CPT category II Code: 2021F Pts 18yrs+ with diagnosis of Diabetic Retinopathy with DFE
Documentation must include – Level of severity of retinopathy (background, non-proliferative (mild, moderate, severe etc), proliferative) – If macular edema is present or absent Diagnosis codes – 362.01 Background diabetic retinopathy – 362.02 Proliferative diabetic retinopathy – 362.03 Nonproliferative retinopathy, NOS – 362.04 Mild nonproliferative diabetic retinopathy – 362.05 Moderate nonproliferative diabetic retinopathy – 362.06 Severe nonproliferative diabetic retinopathy Modifiers -1P, -2P, -8P JAM Measure 19: Diabetic Retinopathy Communication with Physician Managing Diabetes Care
CPT category II Code: 5010F (Findings of exam communicated) & G8397 (DFE performed documenting presence or absence of macular edema & level of severity of retinopathy) both required – G8398 dilated macular exam not performed Patients 18 years+ diagnosed w DR and DFE, at least once per reporting period, documented verbally or by letter Diagnosis codes – 362.01 Background diabetic retinopathy – 362.02 Proliferative diabetic retinopathy – 362.03 Nonproliferative retinopathy, NOS – 362.04 Mild nonproliferative diabetic retinopathy – 362.05 Moderate nonproliferative diabetic retinopathy – 362.06 Severe nonproliferative diabetic retinopathy Modifiers - -1P added for 2011, all others fine
JAM Medicare PQRS Maintenance of Certification
Must participate in PQRS program over a 12 month
period as well as participate in a qualified maintenance of certification program such as American Board of Optometry (ABO) – Must exceed minimum participation levels for certification program Incentive bonus is 0.5%
JAM OIG Audits / Work Plan
Ophthalmological services – 92xxx codes – Reviewing claims during 2011
– 6.8 billion in claims by eye MDs & ODs – Focus on 92004/92014, other 92- included E/M Services: Use of modifiers – Modifiers -25 July 1 2013 policy statement warning not to use -25 for same day surgery – Bilateral intravitreal injections Sequestration – 2% payment reductions across the board in Medicare claims beginning April 1, 2013
– Includes a 2% reduction in EHR incentive bonus JAM
OIG Work Plan Ophthalmological services – New – Reviewing claims during 2011 – $6.8 Billion paid to ophthalmologists & optometrists in 2011 – 8.31% of all claims paid to all physicians in all specialties – 92004 was 12th highest paid code used in all specialties – 66984 was 5th highest paid code – 99xxx E&M codes not included, not specialty specific E/M Services: Use of modifiers – Modifiers -25 – Bilateral intravitreal injections http://oig.hhs.gov/reports-and- publications/archives/workplan/2013/Work-Plan-2013.pdf
JAM OIG Work Plan Rank CPT Services 5 66984 Cat-IOL 12 92014 Comp eye exam, est pt 26 92012 Interm eye exam, est pt 31 92135 Scanning laser 52 92004 Comp eye exam, new pt 63 66984 Cat-IOL, complicated 67 00142 Anesthesia for proc, eye, lens 73 92083 Visual field, full 103 92250 Fundus photography 141 67228 Treatment of exten or prog retinopathy 148 15823 Blepharoplasty 178 92136 Ophthalmic biometry w IOL power calc
JAM Recovery Audit Contractors RAC
Evaluating RAC performance 2010 & 2011
Completed 3 year demonstration project in 2012 Congress will mandate a nationwide implementation of a permanent RAC program for Medicare part A & B Mandates by Tax Relief & Health Care Act 2006 and Affordable Care Act Tool used include comparative billing reports – Shows specific provider billing patterns compared to peers
JAM Health Insurance Portability and Accountability Act of 1996 President Clinton & USAG J. Reno
– #2 priority: prosecution of health care fraud – $104 Million: Appropriations to HHS – $70 Million: OIG – $47 Million: FBI fraud investigation unit – Criminal offenses expanded – $10,000 fine / line item violation – suspension of payment and participation from program – Yielded $23 return on every $1 spent in 1997
JAM Qui Tam Relaters
Amendment to False Claims Act of 1986 Encourages private individuals to sue in the government’s behalf Whistleblowers - 30% of recoveries – $1 Billion paid since 1987 in Qui Tam actions Compliance Plan – Eliminates aggressive or conservative billing philosophies – Removes incentives for whistleblowers – Improves collections while reducing audit risks
JAM Top 10 Procedure Codes – Optometry Missouri / Jan-June 2007 / 495 Providers 92014 $1,369,645 99214 $ 634,210 92004 $ 562,906 92012 $ 551,297 99213 $ 541,616 66984 $ 395,125 92250 $ 339,862 92083 $ 277,708 99203 $ 199,510 92135 $ 195,427 JAM 2012 Comprehensive Error Rate Testing (CERT)
There has been a HUGE increase in CERT audits of E/M services since October 2011 From April 2009-May 2010, E/M services accounted for 28 billion in Medicare Part B payments – Estimated 8.4% billed incorrectly Providers encouraged to review 1997 E/M Guidelines for compliance
JAM 2011 CMS Optometry Probe Results
Prepayment review of 100 services from 100 claims
Probe: CPT 99213 (random) Results – 66% allowed as billed – 34% denied 23% No documents submitted 5% Services not documented in medical record 3% Non-covered services 3% Not medically necessary
JAM Code Set Adoption in HIPAA
CPT-4: Current Procedure Terminology
CDT: Code on Dental Procedures and Nomenclature ICD-9-CM (Volume 1,2): International Classification of Diseases (Implementation of ICD-10 is October 1, 2014!!) ICD-9-CM (Volume 3): inpatient disease codes NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding System
JAM
Medicare – Just Give Me The Numbers
Longevity Revolution – First year of Baby Boomers hitting 65 years of age – 10,000/day turn 65 years of age – An individual turns 60 years of age every 8 seconds – If you live until age 65, average life expectancy is age 84 47, 672,971 Medicare beneficiaries in US – 15% of total population Cataract surgery is the most common surgical procedure in US in Medicare beneficiaries – Also boasts best outcomes – Lowest complication rate JAM Medicare – Distribution by Age (2004)
65-69 23.2 %
70-74 19.9 % 75-79 17.3 % 80-84 12.9 % 85+ 11.0 %
JAM AOA Optometric Practice Profiles 2005
VSP – 21%
Other vision plans – 8% Medicare – 19.1% (fastest growing share of revenues) Medicare HMOs – 3% Medicaid – 7% HMOs (private sector) – 8% Out of pocket – 35% Respondents - 90% self-employed, 47% solo, 24% group, 86% male, mean years in practice 24.2 years JAM
INTRODUCTION
CMS CPT
ICD Medicare Major Medical E/M Coding (99XXX) Eye Coding (92XXX) Special Ophthalmic Codes
JAM E/M GUIDELINES
New/Established Patient Chief Complaint History of Present Illness Family History Past History Social History – New additions level of education, sexual history, marital status/living arrangements Review of Systems Time
JAM E/M DESCRIPTORS
History *
Examination* Medical Decision Making* Counseling Coordination of Care Nature of the Presenting Problem Time
JAM CATEGORIES OF SERVICE Office Visits (E/M Codes) – New 99201-99205
– Estab 99211-99215 Office Visits (Eye Codes) – New 92002-92004 – Estab 92012-92014 Consultations (E/M Codes) – ELIMINATED for Medicare, Medicaid, Tricare and Medicare Advantage HMOs and when any of these are secondary payors – Can still be used for other commercial plans JAM SELECTING AN E/M LEVEL
Identify Category of Service
Identify Extent of History Taking Identify Extent of Examination Identify Complexity of Medical Decision Making Review E/M Descriptors
JAM E/M CODING - OFFICE VISITS
New Patient (3 of 3)
– 99201 - PFH / PFE / SDM / 10 – 99202 - EFH / DFE / SDM / 20 – 99203 - DH / DE / LDM / 30 – 99204 - CH / CE / MDM / 45 – 99205 - CD /CE / HDM / 60
JAM E/M Coding - Office Visits
Established Patient (2 of 3)
– 99211 - Minimal / 5 – 99212 - PFH / PFE / SDM / 10 – 99213 - EFH / EFE / LDM / 15 – 99214 - DH / DE / MDM / 25 – 99215 - CH / CE / HDM / 40
JAM DOCUMENTATION OF HISTORY
Problem Focused History (PFH)
– CC / 1-3 HPI Expanded Problem Focused History (EPF) – CC / 1-3 HPI / Ocular ROS Detailed History (DH) – CC / 4 HPI / Ocular ROS / ROS-2 / 1 OF 3 PFSH Comprehensive History (CH) – CC / 4 HPI / Ocular ROS / ROS-10 / 3 OF 3 PFSH (NEW) OR 2 OF 3 PFSH (ESTAB)
JAM Eye Examination Documentation
VA / CVF / Pupils & Iris / Adnexa Bulbar & Palp Conjunctiva EOM SLE: Cornea / Lens /AC IOP / Optic Nerve / Posterior Segment Neurologic: Orientation (Time / Place / Person) Psychiatric: Mood & Affect (Depression /Anxiety /Agitation) JAM DOCUMENTATION OF EXAMINATION Problem Focused Exam (PFE)
– Limited Exam / l - 5 Elements Expanded Problem Focused Exam (EPF) – Limited Exam / 6 Elements Detailed Exam (DE) – Extended Exam / 9 Elements Comprehensive Exam (CE) – Complete Single System Exam – All Elements JAM Medical Decision Making
Straightforward (SF)
– # Dx / Rx Options - Min / Data - Min / Risk - Min Low Complexity (LC) – # Dx / Rx Options - Lim / Data - Lim / Risk - Low Moderate Complexity (MC) – # Dx / Rx Options - Mult / Data - Mod / Risk -Mod High Complexity (HC) – # Dx / Rx Options - Ext / Data - Ext / Risk - High
JAM Comprehensive Ophthalmological Service 92004 / 92014 Complete system evaluation,
Need not be performed at one session Integrated services where med decision making cannot be separated from examination methods Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy retinoscopy, tonometry, or motor evaluation is not applicable Comprehensive Ophthalmological Service 92004 / 92014 Includes history, medical observation, external &
ophthalmoscopic examinations, gross visual fields, sensorimotor examination Often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry Always includes initiation of diagnostic and treatment programs Comprehensive Ophthalmological Service 92004/92014
Always includes initiation of diagnosis and treatment programs – includes the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services
JAM Intermediate Ophthalmological Service 92002 / 92012 Evaluation of new or existing condition, complicated
with a new diagnostic or management problem not necessarily relating to the primary diagnosis Integrated services where med decision making cannot be separated from examination methods Includes history, medical observation, external & adnexal, & other diagnostic procedures as indicated; may include use of mydriasis for ophthalmoscopy
JAM 2004 New HCPCS Codes “S” codes are useful for some private insurers Medicare and other federal payers do not recognize them They are useful when CPT does not have a code to accurately describe the service (i.e. LASIK, PTK, PRK, corneal topography) or for invoicing self-pay patients. They specifically describe “routine exams” including refractions and permit a different charge
JAM HCPCS “S” Codes
S0620 Routine ophthalmologic exam including
refraction; new patient
S0621 Routine ophthalmologic exam including refraction; established patient S0625 Digital screening retina
JAM 2014 Medicare Physician Fee Schedule Physicians faced a 24% cut in payment effective January 1, 2014 based on Sustainable Growth Formula
This is the 13th time the SGF resulted in a payment cut, although all have been averted by Congress except 2002 December 12, 2013 House passed legislation with amendment that postpones pay cuts on January 1 2014 3 month reprieve provides lawmakers time to complete full medicare pay reform process – During reprieve a fee cut is replaced by a 0.5% update
JAM 2014 Medicare Physician Fee Schedule House committee legislation includes 3 years of 0.5% updates until 2017, then replaced by new value based
system. Original bill froze payments for 10 years Senate committee passed its version of pay reform which freezes payments for 10 years Growing differences between House & Senate versions make final resolution of the SGF repeal more challenging
JAM Pathway for SGR Reform Act of 2013 Obama signed into law on December 26, 2013 Prevents scheduled fee cuts in Medicare Provides for 0.5% update Extends several provisions of the Middle Class Tax Relief Act of 2012 (Job Creation Act of 2012)
JAM 2014 Medicare Fee Schedule
99201 $ 43.03 99211 $ 19.93
99202 $ 73.21 99212 $ 43.03 99203 $ 106.51 99213 $ 71.76 99204 $ 162.50 99214 $ 105.16 99205 $ 201.26 99215 $ 140.81
92002 $ 81.34 92012 $ 85.66 92004 $ 148.59 92014 $123.76
JAM Meaningful Use – Stage 1 Changes 2014 HHS requires all EHR systems to meet both stage 1 and stage 2 MU in order to be certified for use in government incentive programs, even if attempting to meet stage 1 – System updates will be required! Stage 1 MU objectives now require participants to provide patients with timely access to their health information online Stage 1 now requires blood pressure & height / weight Stage 2 MU provides functionality to make PHI available securely online, engages patients, increases exchange of PHI between providers JAM
Meaningful Use – Stage 2 Must use computerized Physician order entry (CPOE) Must use online clinical decision support Must use adverse drug interaction warnings on specified number of patients Must use e-prescribing Must provide patient access to PHI via secure websites and email Must conduct follow up electronically and answer patient questions electronically EHRs must have secure interconnectivity meeting Nationwide Health Information Network standard – Direct Access Technology JAM
Meaningful Use – Stage 3 CMS delays 3rd stage of MU requirements for implementation of EHR system
Under new guidelines, Stage 2 MU extended through 2016 Stage 3 requirements begin in 2017 for providers that complete Stage 2 requirements in 2015 and 2016 Until now providers who began MU program by 2012 had until 2014 to meet MU stage 2 Practitioners entering the program in 2014 can still earn a total of $6,000
JAM
Refraction 92015 Non-covered service
Can be billed to beneficiary – failure to do so results in lost revenues Reminders – Charge only for “Rx-able” refractions – Do not forget to charge for the final refraction when changing spectacles in a post-operative cataract patient
JAM Gonioscopy 92020 Bilateral
Requires documentation – describe visible angle structures No limitations to diagnostic groups in most states Fee $ 27.12
JAM Visual Field 9208x
Bilateral
Requires Interpretation – separate report form – narrative in body of medical record, on date of service Fee (-81) / $ 34.29 Fee (-82) / $ 49.20 Fee (-83) / $ 65.03
JAM Extended Ophthalmoscopy 92225 / 92226 Unilateral
Initial (-225) vs. Subsequent (-226) Implies detailed, extra ophthalmoscopy – document fundus lenses used Modifiers RT /LT Requires retinal drawings & interpretation – sizes, colors and dimensions carrier specific Fee 92225 ($ 27.13) 92226 ($ 24.38)
JAM Fundus Photography 92250 Bilateral
Not Bundled Requires Interpretation Fee $ 69.81
JAM External Ocular Photography 92285 Report for documentation of medical progress
– Ex.: close-up photography, slit lamp photography, goniophotography, stereo-photography Bilateral Not Bundled Requires Interpretation and report Fee $ 20.79
JAM Special Anterior Segment Photography 92286 With specular endothelial microscopy and cell count
– Ex: Konan specular microscope Bilateral Not Bundled Requires Interpretation and report Fee $ 37.95
JAM Special Anterior Segment Photography 92286 364.00-364.04 iridocyclitis 364.10-364.11 chronic iridocyclitis 364.21 Fuch’s heterochromic iridocyclitis 364.22 glaucomatocyclitic crisis 364.23 lens induced iridocyclitis 364..24 VKH syndrome 364.51 essential iris atrophy 364.52 iridoschisis 364.53 pigmentary iris degeneration 364.54 pupillary margin degeneration
JAM Special Anterior Segment Photography 92286 364.55 Miotic Cysts of pupil margin
364.56-364.61 degenerative changes of anterior structures 366.21-23 Traumatic cataract 366.32 cataract in inflammatory disorder 366.33 cataract in ocular neovascularization 371.20-24 corneal edemas 371.32-33 folds or rupture in descemet’s membrane 371.50, -.57,-.58, corneal dystrophy JAM Special Anterior Segment Photography 92286 371.82 corneal edema due to contact lens 379.31 aphakia 379.32 subluxation of lens 379.33 anterior displacement of lens 743.20-23 buphthalmos 906.5 late effect of burn of eye/face 940.2 alkaline burn of cornea/conj 940.3 acid burn of cornea/conj 940.4 other burn of cornea/conj V42.5 cornea replaced by transplant
JAM Special Anterior Segment Photography 92286 996.51 mechanical complication of prosthetic corneal graft
996.60 infection/inflammation due to unspecified implant and graft 996.69 complication of other implant or graft 998.89 complication of other transplanted organ 998.59 other postoperative infection 998.82 cataract fragments in eye following cataract surg V53.1 fitting & adjusting specs or CL after intraocular surgery
JAM Tear Osmolarity Testing 83861 Unilateral
– Paired or cross walked to code 84081 Applies to TearLab’s Osmolarity Device – Novel “Lab-on-a-chip” – Point of care, 50nl sample of tear fluid – Sample-to-answer in less than 30sec – CLIA waiver granted Requires Interpretation & report Fee $23.25
JAM Computerized Corneal Topography 92025
Bilateral or unilateral Requires interpretation & report No limitations to diagnostic groups in most states Fee $ 37.56
JAM 92025 Corneal Topography
ICD-9 Codes that Support Medical Necessity – 367.22* Irregular astigmatism
– 371.00 Corneal Opacity Unspecified – 371.23 Bullous Keratopathy – 371.50 Hereditary Corneal Dystrophy Unspecified – 371.52 Other Anterior Corneal Dystrophy – 371.57 Endothelial Corneal Dystrophy – 371.60 Keratoconus Unspecified – 371.61 Keratoconus Stable Condition
JAM 92025 Corneal Topography
ICD-9 Codes that Support Medical Necessity – 371.62 Keratoconus Acute Hydrops
– 372.40 Pterygium Unspecified – 996.51 Mechanical Complication Prosthetic Corneal Graft – V42.5 Cornea Replaced by Transplant – V45.61* Cataract Extraction Status – V45.69* Other States Following Surgery of Eye /Adnexa – *367.22 must be accompanied by V45.61 or V45.69 – *V45.61 must be accompanied by 367.22 – *V45.69 must be accompanied by 367.22
JAM Scanning Computerized Ophthalmic Diagnostic Imaging 92132 Unilateral or bilateral Applies to anterior segment evaluations – Carl Zeiss / Optical Coherence Tomography (Cirrus) – Optovue / (RTVue, iVue) Requires Interpretation & report Fee $ 35.66
JAM Scanning Computerized Ophthalmic Diagnostic Imaging 92132 190.0, 190.3 Malig neoplasm of eyeball, ecept conj, cornea, retina or choroid 190.3 malignant neoplasm of conjunctiva 190.4 Malignant neoplasm of cornea 190.6, 190.8 Malignant neoplasm of choroid, other sites 224.0 Benign neoplasm of eyeball except conjunctiva, cornea, retina, or choroid 224.3 Benign neoplasm conjunctiva 224.4 Benign neoplasm of cornea 224.6, 224.8 Benign neoplasm of choroid, other sites 360.51 Foreign body in anterior chamber (magnetic) 360.61 Foreign body in anterior chamber JAM
Scanning Computerized Ophthalmic Diagnostic Imaging 92132 364.51 Essential iris atrophy
364.53 Pigmentary iris degeneration 364.54 Degeneration of pupillary margin 364.71 Posterior synechia 364.72 Anterior synechia 364.75 Pupillary abnormalities 364.76 Iridodialysis 364.77 Recession of chamber angle 364.82 Plateau iris syndrome 365.02 Anatomical narrow angle 365.20-365.89 Primary angle closure and other glaucomas JAM Scanning Computerized Ophthalmic Diagnostic Imaging 92132 366.16 Nuclear sclerosis
370.00-370.07 Corneal ulcers 371.00-371.09 Corneal opacities 371.20-371.24 Corneal edema (includes due to CL) 371.57 Endothelial dystrophy 372.40-372.45 Pterygium 379.31 Aphakia 379.32 Subluxed lens 996.51 Mechanical complication of corneal graft 996.53 Mechanical complication of ocular lens prosthesis 996.69 Infection & Inflammation due to other int prosthetic device implant or graft JAM Fitting CL for Ocular Surface Disease 92071 Unilateral; Use –RT/-LT or -50
Do not report 92071 in conjunction with 92072 Report supply of lens separately with 99070 or appropriate supply code Fee $33.65
JAM Fitting CL for Management Keratoconus 92072 Initial fitting
– For subsequent fittings, report E/M services or general ophthalmological services Do not report 92072 in conjunction with 92071 Report supply of lens separately with 99070 or appropriate supply code Unilateral payment; Use –RT/-LT or -50 Fee $126.11
JAM Serial Tonometry 92100 Bilateral
Requires Interpretation & Report – Example: Angle closure glaucoma – multiple measurements over time Fee $ 79.89
JAM Pachymetry 76514 Bilateral
Measurement of central corneal thickness (CCT) proven by Ocular Hypertension Treatment Study (OHTS) to be standard of care in diagnosis and management of glaucoma, glaucoma suspect and ocular hypertension Also billable for keratoconus, corneal transplants, cataracts with corneal dystrophies, guttata, edema Requires Interpretation & Report Fee $ 14.39
JAM Scanning Computerized Ophthalmic Diagnostic Imaging 92133 Unilateral or bilateral Applies to glaucoma or optic nerve evaluations – Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis) – Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus) – Optovue / (RTVue, iVue) – Marco / Retinal Thickness Analyzer (RTA) Requires Interpretation & report Fee $ 44.37
JAM Scanning Computerized Ophthalmic Diagnostic Imaging - 92133 360.30-360.34 Hypotony and flat chamber
354.22 Glaucomatocyclitic crises 365.00-365.04 Glaucoma suspect, OCHTN 365.10-365.15 Open angle glaucoma 365.20-365.24 Primary angle closure glaucoma 365.31-365.32 Steroid induced glaucoma 365.41-365.44 Glauc w chamber anomalies 365.51 Phakolytic glaucoma 365.52 Pseudoexfoliation glaucoma 365.59 Glaucoma assoc w lens disorders
JAM Scanning Computerized Ophthalmic Diagnostic Imaging - 92133 365.60-365.65 Glaucoma assoc w ocular trauma
368.40-368.45 Visual field defects 376.00-376.9 Acute inflammations of the orbit 377.00-377.03 Papilledemas 377.04 Foster-Kennedy 377.10 Optic atrophy 377.14-377.16 Glaucomatous atrophy 377.21 Drusen 377.22 Crater like holes of optic disc 377.23 Coloboma of optic disc
JAM Scanning Computerized Ophthalmic Diagnostic Imaging - 92133
377.24 Pseudopapilledema 377.41-377.49 Ischemic optic neuropathies 377.51-377.54 Disorders of optic chiasm assoc w pit neoplasms or inflammatory disorders 377.61-377.63 Disorders of other visual pathways assoc w neoplasms or inflammations 743.20-743.22 Buphthalmos 743.57-743.58 Cong anomalies of optic disc & vasc anomalies
JAM Scanning Computerized Ophthalmic Diagnostic Imaging 92134 Unilateral or bilateral Applies to retinal evaluations – Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis) – Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus) – Optovue / (RTVue, iVue) – Marco / Retinal Thickness Analyzer (RTA) Requires Interpretation & report Fee $ 45.35
JAM Scanning Computerized Ophthalmic Diagnostic Imaging - 92134 190.6, 190.8 Malignant neoplasm choroid
224.6, 224.8 Benign neoplasm choroid or other sites 360.11 Sympathetic uveitis 360.21 Progressive high (degenerative) myopia 360.30-360.34 Hypotony, flat chamber 361.00-361.07 Retinal detachments 361.10 Retinoschisis 361.2 Serous retinal detachment 361.81 Traction detachment 362.01-362.06 Diabetic retinopathy, background to severe NPD
JAM
Scanning Computerized Ophthalmic Diagnostic Imaging - 92134 362.07 Diabetic macular edema
362.10-362.18 BDR, retinal vasculitis 362.31-362.32 Central or branch retinal artery occlusion 362.35-362.37 Central or branch retinal vein ooclusion 362.40-362.43 Retinal layer separation, hemor detach RPE 362.50- 362.77 Macular degeneration, retinal dystrophies involving Bruch's membrane 362.81 Retinal hemorrhage 362.82 Retinal exudates and deposits 362.83 Retinal edema JAM Scanning Computerized Ophthalmic Diagnostic Imaging - 92134 363.00-363.08 Focal chorioretinitis
363.10-363.15 Disseminated chorioretinitis 363.20-363.35 chorioretinitis unspecified 363.43 Angioid streaks 363.61 Choroidal hemorrhage 363.63 Choroidal rupture 363.70-363.72 Choroidal detachmts 376.00-376.9 Acute inflammations of orbit 379.11-379.19 Scleral ectasia and other scleral disorders 379.21-379.29 Vitreous degenerations & other disor of vitreous 921.3 Contusion of eyeball JAM Correction Trichiasis 67820* Epilation
By forceps ICD-9 – 374.05 Trichiasis without entropion – 374.01 Senile entropion Global days - 000 Fee $ 51.75
JAM Removal of Foreign Body 65205*
External Eye, Conjunctiva – superficial – scleral, non-perforating ICD-9 – 930.18 FB in cul-de-sac Global days - 000 Fee $ 56.97
JAM Removal of Foreign Body 65210* External Eye, Conjunctiva – embedded (includes concretions) – subconjunctival – scleral, non-perforating ICD-9 – 930.18 FB in other sites or combined sites Global days - 000 Fee $ 70.31
JAM Removal of Foreign Body 65222*
External Eye, Corneal – with Slit Lamp ICD-9 – 930.0 FB in cornea Global days - 000 Fee $ 69.04
JAM Sensorimotor Examination 92060 Quantitative measurement of ocular deviation
– document all major fields of gaze Bilateral Requires interpretation and report Fee $65.27 92065 – Orthoptic and / or pleoptic training, with continuing medical direction and evaluation Fee $ 53.98
JAM Dilation of Lacrimal Puncta 68801* With or Without Irrigation
ICD-9 – 375.22 Epiphora, insufficiency of drainage – 375.42 Chronic Dacryocystitis – 375.52 Stenosis, Lacrimal Punctum – 375.56 Nasolacrimal Duct Obstruction Fee $ 128.04
JAM Punctal Occlusion By Plug 68761 Temporary (collagen) or Permanent (Silicone)
Payment is per puncta (modifiers required) – E1=left upper E3=right upper – E2=left lower E4=right lower Global period - 10 days Supply code-included in procedure code, not separately billable Fee $151.71
JAM Punctal Occlusion By Plug 68761 ICD-9
– 370.21 Punctate Keratitis – 370.23 Filamentary Keratitis – 370.34 Exposure Keratitis – 370.80 Other forms of Keratitis – 370.90 Unspecified Keratitis – 371.42 Recurrent Corneal Erosion – 374.41 Eyelid Retraction – 375.15 Unspecified Tear Film Insufficiency
– 710.20 Sicca Syndrome; use additional systemic manif.JAM code Modifiers – 79 Inside post-operative global period – 50 Bilateral Procedure – 24 Unrelated Service / Same Doctor – 79 Inside Global Period – 25 Separate Service / Same Doctor / Same Day – 52 Reduced Service / Informational / Not Reduced Fee – 54 Surgical Care Only – 55 Post-Op Care Only – 51 Multiple Procedures – RT / LT Right / Left – E 1- E4 Identifies Puncta – 52 Reduced service JAM Comanagement of Surgery
Procedures / 66984 / $ 658.82 Global Periods - 90 days
Value - up to 20% MD name and NPI Modifiers (-54 on MD claim, -55 on OD claim and RT/LT) Range Dates – from transfer date to end of 90 day global Rules - Medicare Transfer Agreement in MD record Correspondence Legal/Political/Inter-professional Issues
JAM Complicated Cataract Surgery 66982 New CPT code for 2001 / $ 818.06
Extracapsular cataract extraction with insertion of IOL, complex, requiring devices or techniques not generally used in routine cataract surgery – 2-3% of all cataract surgeries involve extraordinary work iris expansion devices, suture support for IOL, posterior capsulorrhexis, small pupil, subluxed lens, Pseudoexfoliation, trauma, Marfan’s, glaucoma, uveitis pediatric population Advanced, white, hard cataract JAM Introducing ICD-10-CM
John A. McGreal Jr., O.D. Missouri Eye Associates
McGreal Educational Institute
Excellence in Optometric Education
Understanding the Basics & Getting Ready
Differences between ICD-9 & ICD-10 How the ICD-10CM is laid out How to Use the Alphabetic Index How to Use the Tabular List How to Use the Index of injuries How to Use the Table of Drugs & Chemicals How to Understand new Abbreviations How to Use Placeholders How to Use Code Extensions
Understand laterality JAM
The Lilliputians Take Control of the Healthcare Giant
ICD-9 has 13,000 codes ICD-10 has 140,000 Effective date – October 1, 2014 Transition will be difficult as there is little in common with our current coding paradigms Requires doctors, not staff to do the specific coding Every artery and nerve has been issued a number Number of physicians = 800,000/ 35% own their own practice (Source Accenture with data from Medical Group management Assoc and AMA)
JAM Why Convert to ICD-10-CM?
Clinical modification of WHO’s ICD-10 – Clinical emphasizes the intent to serve as a tool in classification of morbidity data for indexing, medical records care review, medical & ambulatory care programs, health statistics Better understand complications Better design robust algorithms Track outcomes – To describe the “clinical” picture the codes must be more precise – Far exceeds ICD-9 in number of concepts and codes – Disease classification expanded to include health
related conditions and provides greater specificity JAM Improvements Over ICD-9
Index MUCH longer
– Ex 28 pterygium, 69 conjunctivitis, 12 astigmatism codes Adds information relevant to ambulatory & MC encounters Expanded injury codes Combination diagnosis/symptom codes Addition of 6th & 7th characters Incorporates common 4th & 5th digit subclassification Laterality Allows further expansion JAM Organization of ICD-10-CM Alphabetical Index – Alphabetical list of terms and corresponding codes
– Index of Diseases & Injury – Table of Neoplasm – Table of Drugs & Chemicals – Index of External causes of injury Tabular List – Chronological list of codes – Divided into chapters – Based on body systems
JAM Organization of ICD-10-CM Alphabetical Index – Define terms
– Provide directions – Provides coding instructions Tabular List – Categories – 3 characters from Chapter 7 Disorders of Eye H00-H59 – Subcategories 4th character further defines site, etiology, manifestation or state of disease or condition 5th & 6th character increases specificity JAM Tabular List Detail Chapter 1 Infectious and parasitic diseases (A00-B99) Chapter 2 Neoplasms (C00-D49) Chapter 3 Diseases of Blood and blood forms (D50-D89) Chapter 4 Endocrine, nutritional, metabolic (E00-E90) Chapter 5 Mental & behavioral (F01-F99) Chapter 6 Nervous system (G00-G99) Chapter 7 Eye & adnexa (H00-H59) Chapter 8 Ear and mastoid (H60-H95) Chapter 9 Circulatory system (I00-I99) Chapter 10 Respiratory system (J00-J99) Chapter 11 Digestive system (K00-K94) JAM Tabular List Detail Chapter 12 Skin & subcutaneous (L00-L99) Chapter 13 Musculoskeletal (M00-M99) Chapter 14 Genitourinary (N00-N99) Chapter 15 Pregnancy & childbirth (O00-O99) Chapter 16 Conditions of perinatal period (P00-P96) Chapter 17 Congenital / Malformations (Q00-Q99) Chapter 18 Signs/Symptoms/abnormal clinical laboratory findings (R00-R99) Chapter 19 Injury, Poisoning, consequences of external causes (S00-T88) Chapter 20 External causes of morbidity (V01-Y99)z Chapter 21 Factors influencing health status & contact with health services (Z00-Z99) JAM Chapter 7: Diseases of Eye/Adnexa Detail H00-H05 Eyelid, lacrimal, orbit H10-11 Conjunctiva H15-H22 Sclera, cornea, iris, ciliary body H25-H28 Lens H30-H36 Choroid/retina H40-H42 Glaucoma H43-H44 Vitreous & globe H46-H47 Optic nerve & pathways H49-H52 Ocular muscles, accomodation, refraction H53-H54 Visual disturbances and blindness H55-H57 Other disorders eye & adnexa H59 Intra-operative & post-procedural complications JAM
Format & Structure Tabular list contains categories, subcategories & codes Characters may be letter or numbers
Categories are 3 characters – Character 1 is alpha All letter used except U – Character 2 is numeric – Character 3-7 are alpha or numeric – Use decimal after 3 characters Subcategories are 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters Laterality specific JAM Placeholder Characters
Character “X” used as a placeholder
– Allows for future expansion – Where it exists it must be used to be valid – Ex S05.8x1A
JAM Placeholder Characters Code extensions (seventh character) have been added for injuries and consequences of external causes (S00-T88), to identify the encounter – “A” Initial encounter – receiving active treatment – “D” Subsequent encounter-use after Pt received active treamt – “S” Sequelae-used for complications/conditions arise as result of injury S only added to injury code, not sequela code Sequela code first, followed by injury code – Ex: S30 superficial injury of abdomen S30.810, code requires extension to indicate episode of care
S30.810A JAM
7th Character
Certain ICD-10-CM categories have 7th digit characters th Applicable 7 character is required within the category If code requires 7th character and there is not 6 characters, a placeholder “X” must be used to fill empty character Ex: S05 Injury of eye and orbit, subsequent visit – S05.00 Looking it up you find “x7th” meaning no 6th character exists but there is a 7th character mandatory – S05.00xD JAM 7th Character Extension
Glaucoma staging by 7th character for severity
1 = mild stage 2 = moderate stage 3 = severe stage 4 = indeterminate 0 = unspecified Ex: low tension glaucoma – Glaucoma/low tension glaucoma/moderate R, severe left – H40.-/ H40.12 / H40.1212, H40.1223
JAM 7th Character Extension
– Category - Chapter 19: Injury, Poisoning and other causes of external S05.- Injury of eye and orbit – Subcategory – Check 5th SO5.0 Injury of conjunctiva and corneal abrasion w/o FB – Specificity – Check 7th SO5.01 Injury of conjunctiva and corneal abrasion w/o FB, right eye – Code – SO5.01xA Injury on conjunctiva and corneal abrasion w/o FB, right eye, initial encounter
JAM Laterality
For bilateral sites, final character of code indicates laterality (-1 = R, -2 = L, -3 bilat, -0 or -9 nonspec)
Unspecified side codes if side not identified in medical record If no bilateral code provided and condition is bilateral – Assign separate codes for both left and right Ex: – H43.811 Vitreous degeneration, right side – H43.812 Vitreous degeneration, left side – H43.813 Vitreous degeneration, bilateral – H43.819 Vitreous degeneration, unspecified
JAM Laterality
Exceptions are when eyelid coding
Ex: – H02.011 Cicatricial entropion, right upper lid – H02.012 Cicatricial entropion, right lower lid – H02.013 Cicatricial entropion, right unspecified lid – H02.014 Cicatricial entropion, left upper – H02.015 Cicatricial entropion, left lower – H02.016 Cicatricial entropion, left unspecified lid – H02.019 Cicatricial entropion, unspecified eye, unspecified lid
JAM Combination Coding
Single code used to describe 2 diagnoses Diagnosis with a manifestation
– Ex: E11.321 – Type 2 DM with mild non-proliferative retinopathy with macular edema Diagnosis with associated complication – Ex: H59.032 CME following cataract surgery, left eye
JAM Abbreviations
NEC “not elsewhere classifiable” NOS “not otherwise specified” “and” represents and / or “code also” instructs two codes may be required [ ] Brackets identify manifestation codes ( ) parenthesis terms are non essential modifiers : Colon incomplete term needing more modifiers
JAM Excludes Codes
Excludes 1 – pure excludes notes
– Means “NOT CODED HERE” – Indicated code exclude should never be used same time as code above it Ex congenital vs acquired condition Exclude 2 – “Not included here” – Condition excluded is not part of the condition represented by the code
JAM Etiology / Manifestation Convention
Some conditions have underlying etiology and multiple
body system manifestations due to the etiology Coding convention requires underlying condition be sequenced first, followed by manifestation – “use additional code” note exists at etiology codes – “code first” note at the manifestation code Ex; Dementia in Parkinson’s disease – Code G20 represents etiology – [F02.80 or F02.81] represents manifestation of dementia With behavioral or without behavioral disturbances JAM General Coding Guidelines
Locating a code in ICD-10-CM – Locate term in Alphabetic Index – Then verify code in the Tabular List – Read and be guided by instructional notations appearing in both – Essential to use BOTH Alphabetic index doesn’t always provide FULL code Need Tabular List to assign laterality and 7th character
JAM Sign & Symptoms
Codes that describe symptoms and signs, as opposed to
diagnosis Are accepted when a definitive diagnosis has not been established Chapter 18 Expected to document behavioral and psychiatric issues – R46.0 Low level of personal hygiene – R19.6 Halitosis – R14.3 Flatulence – R45.84 Worries JAM Acute & Chronic Conditions Acute & Chronic – Code acute or chronic
– If condition is both, code both with acute first Late Effects (Sequela) – Residual effect after acute phase of illness or injury has terminated – No time limit – Coding requires 2 codes sequenced in order Condition first Late effect code second
JAM External Cause Codes
Chapter 20
Use full range of external cause codes to completely describe: – the cause, – the intent, – the place of occurrence, – and if applicable the activity of the patient at the time of the event and – the patient’s status for all injuries and other health conditions due to an external cause JAM Chapter 4 Endocrine, etc Diabetes mellitus – Combination codes that include
Type of Diabetes / Body system affected Complications affecting body system – Sequencing depends on reason for the encounter 5 Categories – E08. Diabetes mellitus due to underlying condition – E09. Drug or chemical induced diabetes mellitus – E10. Type 1 diabetes mellitus – E11. Type 2 diabetes mellitus
– E13. Other specified diabetes mellitus JAM Chapter 4 Endocrine, etc E11.9 Type 2 DM without complications E10.339 Type 1 DM with moderate NPDR without
macular edema E11.321 Type 2 DM with mild NPDR with macular edema, AND JUST MAYBE… Z79.4 Long term (current) Use of Insulin (if documented) – All Categories except E10 (Type 1 DM) require use of additional code to identify use of insulin
JAM General Equivalence Mapping
No direct cross walk exist from version 9 to 10
Mapping will greatly assist translation from version 9 Eye code translation is fairly easy EMR / PMS are creating bridges currently – ICD -9 to ICD-10 – ICD-10 to ICD-9 No decimal points in GEM files Three columns in GEM file layouts
General Equivalence Mapping Example ICD9 ICD10 Flags 36610 H259 00000
36611 H2589 10000 “1’ in first flag = approx 36612 H25099 10000 36613 H25039 10000 36614 H25049 10000 36615 H25019 10000 36616 H2510 10000 36617 H2589 10000 36618 H2520 10000
Z Codes
Z codes are analogous to the ICD-9CM “V” codes Most rules of V codes transfer over to the use of Z codes Used to describe routine examinations of many varieties Each with different codes Ex Z00 Encounter for general examination without complaint, suspected or reported diagnosis Ex Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
JAM Steroid Responder Visit Scenario – Old Way
57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS CPT 99214 ICD: 365.04
JAM Steroid Responder Visit Scenario – New Way
57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS CPT 99204
ICD: T38.0x5 – T38.0x1 = accident – T38.0x2 = self harm – T38.0x3 = assault – T38.0x4 = undetermined – T38.0x5 = adverse effect – T38.0x6 = under-dosing ICD: H40.62 Glaucoma secondary to drugs, left eye – Note states “code first” T36-T50 to identify drug
JAM Ocular Trauma Visit Scenario – Old Way
52 YOM hit with golf ball, OS while driving golf cart on 8th hole, with mild hyphema CPT 99215 ICD: 365.65
JAM Ocular Trauma Visit Scenario – New Way 52 YOM with hyphema from golf ball, OS CPT 99205
ICD: – S05.12xA Contusion of eyeball & orbital tissue, left eye, initial en – V86.59xA Driver of golf cart injured in non-traffic accident – W21.04xA Stuck by golfball – Y92.39 Golf course as place of occurrence – Y93.53 Activity, golf Hints – Chapter 19 = injury, poisonings etc (S00-T88) – Chapter 20 = external causes of morbidity (V01-Y99)
JAM Ocular Trauma Visit Scenario – Old Way
32 YOF struck by exotic bird (cockatoo) on vacation, OD, with corneal abrasion CPT 92012 ICD: 918.0
JAM Ocular Trauma Visit Scenario – New Way 32 YOF with corneal abrasion, OD CPT 99205
ICD: – S00.1 Contusion of eye and periocular area – S05.91 Unspecified injury of right eye and orbit – S00.21 Abrasion of eyelid and periocular area – S00.211A Abrasion of eyelid and periocular area, initial encounter – W61.02xA Struck by parrot – W61.12xA Struck by macaw – W61.22xA Struck by other psittacines – W61.62xA Struck by duck
JAM Principles of Healthcare Reform Engage – Pt involved in clinical decision making at
every level (HCR is about INTERACTION) Use of Registry – for outcomes analysis Clinical Decision Support – plug in data / receive support – U of H and U of Az - $15M SHARP Program Patient education – examination summary Standardized communications – coordinated care Attrition – mandates offices know rate and why Principles of Healthcare Reform HCR is about COST SAVINGS
Two ways to save – Capitate – cuts fees without outcomes measured – Coordinated – care systems with outcomes measured Outcomes studies – HCR challenges fees and benefits without outcomes studies – Priority challenge is diagnostic testing for early detection – Best practices, “gaming system”, fee for service model allows technology to take the lead
Principles of Healthcare Reform HCR is about Communication
– MU is NOT HCR Two ways to Communicate – Connect – Direct – Most ODs are NOT involved in electronic communication – Vast majority of EHRs cannot do this yet! Ex CCD problem list from PCP, truly co-managing DM, retina etc Ex Sharing data like OCTs Care coordination assures duplicate testing is not done (political)
Principles of Healthcare Reform Connect – is a set of communications standards based on query method of sharing PHI. It is used by large health systems and hospitals to share PHI with other large systems. It involves a portal where outside providers view data, find what is needed through query and “pull” required information from data Direct – messaging is a set of communication protocols provides secure exchange of PHI between providers over the internet by Health Information Service Providers (HISPs). Data is “pushed” to other providers and is best for independent providers
Principles of Healthcare Reform Health Information Exchange – each state is responsible for establishing a secure communications exchange that links all health care providers together for purpose of sharing PHI. There are 2 technologies supported by the stimulus bill: Connect & Direct. This is NOT a health insurance exchange Health Insurance Exchange – state or federally administered exchange designed to allow patient access to affordable insurance in a less complicated way promoting all patients to acquire health care coverage
Principles of Healthcare Reform Medical Home – health care setting where patients receive comprehensive primary care services, have have ongoing relationship with PCP who directs and
coordinates all care. This is the primary coordinated care model under HCR. Primary care is a core of patient centered delivery system, which involves the patient at high levels in MDM Pay for Performance – payment system in which providers receive incentives for meeting or exceeding quality, cost benchmarks. Some systems penalize for not meeting benchmarks. Goal is improved quality over time
Principles of Healthcare Reform Shared Savings – many P4P systems include incentive payments to providers to reduce cost of providing care through shared savings, with % of actual savings shared back to providers ro ACOs Registry – data repositories that can mine data for outcomes analysis Risk Adjustment – process of increasing or decreasing fees to health plans to reflect higher or lower than expected spending. Designed to compensate plans that enroll older and sicker populations
Principles of Healthcare Reform STARS Rating System - 5 star quality rating system for Medicare Advantage Plans is run by CMS to educate consumers on quality and make data more transparent – Over 50 measures from 5 different ratings systems – Applied to every encounter for every patient covered by any Medicare Advantage plan – CMS will use this data to determine which plans get contract renual after January 2015 – 11of the measure are directly or indirectly affected during an eye examination
CMS Quality & Performance Measure
C01 Breast Cancer Screening 68% 3 C02 Colorectal Cancer Screening 58% 4
C03 Cardiovasc Care Choles screening 88% 4 C04 Diabetes Care Choles screening 88% 4 C05 Glauc testing 66% 3 C06 Annual flu vaccine 68% 3 C07 Improving maint physic health 65% 4 C08 Improve maint mental health 77% 2 C09 Monitoring physical activities 48% 2 CMS Quality & Performance Measure
C10 Adult BMI Assmt 66% 4 C11 Care Old Adults Med review 68% 3
C12 Care Old Adults Func Status review 56% 3 C13 Care Older Adults Pain screening 54% 3 C14 Osteo mangmt in Women w hx frx 21% 1 C15 DM care – eye exam 65% 3 C16 DM – kidney dz monitoring 89% 2 C17 DM – blood sugar controlled 72% 3 C18 DM – cholest controlled 52% 3
CMS Quality & Performance Measure
C19 Control BP 65% 3 C20 RA managmt 74% 3
C21 Improving Bladder control 35% 2 C22 Reducing Risk Falling 59% 3 C23 Plan all cause readmission 12% 3 C24 Getting needed care 85% 4 C25 Getting apt & care quickly 76% 3 C26 Customer service 88% 3 C27 Overall rating of healthcare quality 86% 4
CMS Quality & Performance Measure C28 Overall rating of plan 86% 3 C29 Care coordination 85% 3
C30 Complaints about healthcare 0.26% 3 C31 Beneficiary access & perform probs 65 4 C32 Members choosing to leave plan 11% 4 C33 Healthplan Quality Improvmt --- 3 C34 Plan makes timely decis about appeals 87% 4 C35 Reviewing appeals decisions 83% 3 C36 Call cntr foreign language interpret 83% 4 C37 Enrollmt timeliness 90% 4 CMS Quality STAR Measures example
C15 Diabetes Care – Eye Exam for damage from DM 1 Star <47% 2 Star >47%-<54% 3 Star >54%-<64% 4 Star >64%-<81% 5 Star >81% CMS Quality STAR Measures example
C05 Glaucoma testing - % members over 65 without
prior diag glaucoma or suspect who received glauc test 1 Star <54% 2 Star >54%-<62% 3 Star >62%-<70% 4 Star >70%-<74% 5 Star >74% Principles of Healthcare Reform HEDIS – Healthcare Effectiveness Data & Information Set – Widely used set of performance measures in managed care industry developed & maintained by National Committee on Quality Assurance (NCQA) Consumable data – allows humans to read and also allows ability for computer systems to automatically extract specific data and populate different EHRs, allowing sharing of data but also sharing the effort to enter data. It increases efficiency and lowers costs
Principles of Healthcare Reform ACO – Accountable Care Organization is network of providers to provide full continuum of care, accountable
for quality and cost of care and incentives for success Chronic Care Management – coordinates healthcare and supportive services to improve health status of patients with chronic diseases like DM and asthma, focusing on EBM and patient education to improve self management and increase quality & decrease costs Comparative Effectiveness Research - analyzes the impact of different options for treating a condition in a particular group of patients, focusing on medical risks and benefits and cost risk and benefits of each option
Principles of Healthcare Reform
MU – Meaningful Use is a timeline created for providers to be able to incorporate all features necessary to practice in a coordinated environment where reimbursement is based on outcomes. Total patient experience – addresses the psychology of the patient. Studies show satisfaction affects compliance. More of the focus of new quality measures is directed at patient total experience than it is the care providers deliver
Principles of Healthcare Reform
Transparency – process of reporting provider quality scores to public to allow patients to select providers
– ARRA allows payers to create incentives up to 20% out of pocket to patients who select high scoring providers Medicare is required by law to establish a provider quality reporting webpage and outcomes of all medicare billing is now being completed in preparation for reporting to public via Medicare Physician Quality Compare Website under delvelopement Dry Eye Disease (DED)
CC: “Foreign body sensation”
HPI: OU / 2 yrs / mod / 44 year old perimenopausal female / CL intolerant (SCL), mild blepharitis and MGD VA = 20/70 OU SLE: + SPK diffuse / corneal stains (both), conj stains (both), TBUT = 5 sec, Schirmers = <3mm IOP = 12 Fundus = Normal Dry Eye Disease (DED)
Assessment = DED
Plan – Lid scrubs bid – AFTs q2h (PF) – Lotemax gel qid – Restasis bid – EyePromise EZ Tears PO – D/C SCL – Humidifier – Letter PCP Case Study: Dry Eye Disease Coding
First visit
– E/M 99204 = 370.33 ($168.00) or 92004 ($125.00) – Ant Photo 92085 = ($27.00) Second – E/M 92012 = 370.33 ($85.00) or 99213 ($72.00) Total $280.00 (excludes revenue from supplements)
DED - HCR Principles Demonstrated Engage – Pt involved in decision making; understands
options of prescription vs palliative treatments; non- ocular therapies reviewed; potential for systemic medication involvement; co-morbidities reviewed Clinical Decision Support - discussion of evidence based approach to definitive treatment of DED Patient education – examination summary Standardized communications – coordinated care Monitor Compliance with Audits
Develop a “Documentation” team Monthly Assessment – 10 charts/Provider Report your Results – All staff, residents, students Acknowledge positive & negative variances – RETRAIN, RETRAIN..
Thank you
Missouri Eye Associates McGreal Educational
Institute Excellence in Optometric Education