Contact Lens Coding Essentials

1. Contact Lens Coding Essentials Carla J. Mack, OD, MBA, FAAO April 1, 2009

2. Carla J. Mack, OD, MBAcarla.j.mack@bausch.com • Bausch & Lomb – Vision Care • Director, Global Medical Affairs • Academic liaison • Publications • Compliance • Public relations

3. Carla J. Mack, OD, MBAcarla.j.mack@bausch.com • The Ohio State University • Director of Clinic Services • Associate Professor of Clinical Optometry • Optometric Management Editorial Advisory Board • Coding Column

4. Carla J. Mack, OD, MBAcarla.j.mack@bausch.com • Editor for Contact Lens Spectrum and Contact Lenses Today e-newsletter 2007-2008 • Coding Column in CLS • Diplomate, AAO Cornea and Contact Lens Section

5. Goals • Value • Medical Records and Contracts • The Codes in Play • Tips and Resources

6. Value • Think like a dentist • Education • Experience • Expertise • Attitude/ Mindset • Perform • Look the part

7. Value • What services do you receive free from a health care provider? • Do you expect not to pay when receive services from a health care provider? • What services do your patient’s receive for free?

8. Value Your Services • 2005 Survey-Cleinman Performance Partners Average OD is leaving $100,000 of medically necessary charges on the table EACH year

9. Medically Necessary AMA Definition (1999) • “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, treating, or rehabilitating an illness, injury, disease or its associated symptoms, impairments, or functional limitations in a manner that is: • in accordance with generally accepted standards of medical practice • clinically appropriate in terms of type, frequency, extent, site and duration • not primarily for the convenience of the patient, physician or other health care provider.”

10. In other words….. • The patient must have and illness, injury, or disease that has a symptom, impairment, or functional limitation • A test performed must have an indication (see the previous point), and the result must influence the treatment plan • A treatment must be a standard of care • A treatment cannot be for mere convenience (Cosmetic contact lenses)

11. Medically necessary and NOT • Medically necessary contact lenses • Cosmetic contact lenses

12. Value Your Services • 2001 Study by Dr. Mark Ritson and the London Business School • Found that CL patients are 60% more profitable than spectacle patients

13. Value Your Services Charge enough to stay motivated to continue to understand your practice, as a business, and the nuances of coding! It is not easy and you will receive bad info……it is not as hard as you think either

14. Differentiate • 40,000 practicing ODs in the US • How will you stand out? • Differentiate vs. low cost • Specialty • Staff • Technology • Personality • Communication and information • Efficiency • Community service

15. Insurance Contracts • Contract (VSP, Private insurance companies) • Understand and read • Fee schedules • Balance billing • Medicare • National Carrier Determinations • Local Carrier Determinations

16. Coding: Who is responsible?

17. Medical Record • If you did not write it down, you did not do it. • Record advice and recommendations • Record patient responses and reactions • Tell patients when their actions increase their risk and tell them you are writing it down • Legal Document

18. Why is documentation important? • Chronological, LEGAL DOCUMENT • Deliver high quality patient care • Monitor patient’s immediate tx • Monitor care over time • Enables efficient care

19. Why is documentation important? • Communication internally • Communication externally • other health professionals • Continuity of care

20. Why is documentation important? Accurate and timely payment!

21. Informed Consent Patient has the right to know and understand the risk and benefits of a procedure Patient has the right to know about abnormal examination findings Patient has the right to ask questions Document

22. Payers Vision Insurance Medical Insurance Private Pay Numerically link appropriate CPT with appropriate ICD-9

23. Chief Complaint • Drives the exam • Establishes medical necessity • ‘The patient must have and illness, injury, or disease that has a symptom, impairment, or functional limitation’ • Ongoing throughout the exam • Previous A&P • Link to first diagnosis

24. Chief Complaint Concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in patient’s own words

25. The Codes That Are in Play What You Need to Know About These Codes to Get Paid

26. Current Procedural Terminology • Intermediate or Comprehensive Eye Exam • Evaluation and Management Visit • Consultation • Additional procedures

27. Ophthalmologic Codes • 92004 and 92014 • Comprehensive new • Comprehensive established • 92002 and 92012 • Intermediate new • Intermediate established • VSP guidelines • Definition in CPT book • Billed to vision or medical insurance • Great debate use E/M or eye exam codes

28. Evaluation and Management (E/M) A “new patient” is a patient who has not been examined by you or another doctor in the same specialty in the same practice in the previous 3 years

33. E/M vs. General Ophthalmological Services The great debate…..

34. Consultation Codes • 99241-99245 • Written or verbal request from physician (PA, RN, NP, DC, PT, OT, SW, Psych, attorney, or Ins. Company) • But not patient! • Care or opinion provided • Written report back to physician • Reimbursement is more • Return visits coded as E/M • Not coded as new or established • Code other procedures also http://www.optometric.com/article.aspx?article=100621

36. Additional procedures • 92015 Refraction (both eyes) • 92020 Gonioscopy (both eyes) • 92025 Topography (unilateral or biliateral with I & R) • 92070 Therapeutic CL fitting (R or L) • 92083 Visual field extended (both eyes) • 92285 External Ocular Photography (both eyes with I & R) • 92250 Fundus photography (both eyes with I & R) • 92499 Unlisted Ophthalmologic Service or Procedure (LMN) • 76514 Pachymetry (unilateral or bilateral)

37. Letters of Medical Necessity (LMN’s)

38. More on Documentation for Medical Necessity

39. Contact Lens Services • 92310

40. Contact Lens Services • 92310—Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia • 92311—corneal lens for aphakia, one eye • 92312—corneal lens for aphakia, both eyes • 92313—corneoscleral lens • 92070—Fitting of a contact lens for the treatment of disease, including supply of lens • 92325—Modification of contact lens (separate procedure), with medical supervision of adaptation • 92326—Replacement of contact lens

41. An Important Note About Billing for Contact Lenses From Our Friends at CPT About 92310-92313 • “The prescription of contact lenses includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, gas-permeability). It is NOT a part of the general ophthalmological services. • The fitting of a contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period. • Follow-Up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service. (92012 et seq) • The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code.

42. Contact Lens Fitting: Professional Fee

43. HCPCS Material Codes • V2510—Contact lens, GP, Spherical, per lens • V2511—Contact lens, GP, Toric, per lens • V2512—Contact lens, GP, Bifocal, per lens • V2513—Contact lens, GP, Extended Wear, per lens • V2520—Contact lens, Hydrophilic, Spherical, per lens • V2521—Contact lens, Hydrophilic, Toric, per lens • V2522—Contact lens, Hydrophilic, Bifocal, per lens • V2523—Contact lens, Hydrophilic, Extended Wear, per lens • V2531—Contact lens, GP, Scleral, per lens

44. Important Concepts • The dumbest optometric concept EVER!!! • The “contact lens fitting fee” • The second dumbest optometric concept EVER!!! • The “contact lens check” • Only use the 92070 code for bandage lenses • NDC 80.1 • NDC 80.4

45. National Carrier Policy 80.1 Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, such as bullous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, corneal edema, descemetocele, corneal ectasis, Mooren's ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis, and for other therapeutic reasons. Payment may be made under §1861(s)(2) of the Act for a hydrophilic contact lens approved by the Food and Drug Administration (FDA) and used as a supply incident to a physician's service. Payment for the lens is included in the payment for the physician's service to which the lens is incident. Contractors are authorized to accept an FDA letter of approval or other FDA published material as evidence of FDA approval. (See §80.4 of the NCD Manual for coverage of a hydrophilic contact lens as a prosthetic device.)

46. National Carrier Policy 80.4 Hydrophilic contact lenses are eyeglasses within the meaning of the exclusion in §1862(a)(7) of the Act and are not covered when used in the treatment of non-diseased eyes with spherical ametrophia, refractive astigmatism, and/or corneal astigmatism. Payment may be made under the prosthetic device benefit, however, for hydrophilic contact lenses when prescribed for an aphakic patient. Contractors are authorized to accept an FDA letter of approval or other FDA published material as evidence of FDA approval. (See §80.1 of the NCD Manual for coverage of a hydrophilic lens as a corneal bandage.)

47. Important Concepts • Charge another contact lens service fee if you change the lens design “substantially” • That is, a change that is not an “incidental revision” • Follow up visits are not part of the 923xx codes. The “supervision of adaptation” requirement is met at the first follow-up visit. • Subsequent follow-up visits are a part of a general ophthalmological service—you are medically evaluating the effect of the presence of the contact lens on the ocular tissue

48. Contact Lens “Fitting Fees” • How are docs using? • Global fee • For X time period • For X number of visits • Includes contact lenses • Includes topography • Tiered cost structure

49. Better way… • Be clear on what fitting fee covers • Do bill for contact lens evaluation on ALL contact lens wearers who present for a comprehensive exam (92014, 92015, 92025, 92310) • Do not bundle other billable services • Refraction, topography, etc • Bill based on definition! • Bill again if more than “incidental revision”

50. Contact lens fees • Professional fees high • Complexity, time, expertise • New wearer vs. established wearer • Profit • Material fees • Competitive • Cover cost of lenses and overhead • According to ABB/Con-Cise, highest profit margins are on soft torics and MF • Stock vs. no stock