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Basics of Medical versus Basics of Medical versus Vision CodingVision Coding
Marcus Gonzales, ODMarcus Gonzales, ODTOA Convention 2011TOA Convention 2011
DISCLAIMERDISCLAIMER
This lecture and the concepts within apply to This lecture and the concepts within apply to CPT and Medicare/Medicaid guidelines that are CPT and Medicare/Medicaid guidelines that are currently applicable, but are susceptible to currently applicable, but are susceptible to change over time.change over time.The examples in no way mandate a manner in The examples in no way mandate a manner in which you should practice medicine nor is it the which you should practice medicine nor is it the only way in which one could bill for it. That is an only way in which one could bill for it. That is an individual physicianindividual physician’’s decision.s decision.Any fees presented in these examples in no Any fees presented in these examples in no manner mandate or even suggest fees you manner mandate or even suggest fees you should consider for services rendered. This is should consider for services rendered. This is also an individual physicianalso an individual physician’’s decision.s decision.
Wellness Care vs. Medical CareWellness Care vs. Medical CareTHE Cornerstone IssueTHE Cornerstone Issue
These are INDEPENDENT These are INDEPENDENT examinations examinations –– have nothing to have nothing to do with each otherdo with each other
Can include some of the same Can include some of the same procedures, but they have procedures, but they have different findings and different findings and documentationdocumentation
Eye CareEye CareWe provide wellness care & medical care.We provide wellness care & medical care.
The decision to bill wellness or medical is The decision to bill wellness or medical is not solely based on why the patient is not solely based on why the patient is there or what their insurance coverage is.there or what their insurance coverage is.
It is determined over the entire course of It is determined over the entire course of the exam.the exam.
Medical CareMedical CareIt has nothing to do with:It has nothing to do with:
what special tests you orderedwhat special tests you orderedhow long you spend with the patienthow long you spend with the patientwhether a medical prescription was givenwhether a medical prescription was givenwhat the patient thinks is wrongwhat the patient thinks is wrongwhether the patient knew or didnwhether the patient knew or didn’’t know t know there was a problemthere was a problemwhether or not the patient needs vision whether or not the patient needs vision correction correction And it is And it is NOT limited to red eyes!NOT limited to red eyes!
Medical CareMedical Care
Reimbursed on cognitive thinking and the Reimbursed on cognitive thinking and the subsequent documentation of thesubsequent documentation of the……
SYMPTOMS AND THE SYMPTOMS AND THE ASSOCIATED ASSOCIATED DIAGNOSISDIAGNOSIS
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Medical CareMedical Care
Advantages:Advantages:Higher reimbursementHigher reimbursementPatient may pay less Patient may pay less –– espesp with Medicarewith MedicareValidation/Patient expectationValidation/Patient expectation
Disadvantages:Disadvantages:Get on panelGet on panelWait for reimbursementWait for reimbursementUnique rules Unique rules –– sometimes difficult to know sometimes difficult to know themthemFear of being auditedFear of being audited
Things to RememberThings to Remember……
Any time a patient presents to your Any time a patient presents to your office, you have to rule out a medical office, you have to rule out a medical problem before determining its a problem before determining its a wellness exam.wellness exam.Some medical insurances cover routine Some medical insurances cover routine eye care which usually reimburses eye care which usually reimburses higher!higher!LetLet’’s look at some key differences s look at some key differences between wellness between wellness vsvs medical care.medical care.
Wellness Care vs. Medical CareWellness Care vs. Medical Care
Reimbursement dictated Reimbursement dictated by by payorspayors
Reimbursement dictated Reimbursement dictated by YOU!by YOU!
Morbidity Morbidity –– potential potential mortalitymortality
No real morbidity, NO No real morbidity, NO mortalitymortality
Little to no Little to no ““Rules of Rules of examexam”” –– professional professional judgmentjudgment
““Rules of examRules of exam””cookbook and dictated cookbook and dictated by TOBby TOB
Reimbursement Reimbursement symptom or diagnosis symptom or diagnosis drivendriven
Reimbursement requires Reimbursement requires no driverno driver
MEDICAL CAREMEDICAL CAREWELLNESS CAREWELLNESS CARE
Wellness Care vs. Medical CareWellness Care vs. Medical Care
Reimbursement dictated Reimbursement dictated by by payorspayors
Reimbursement dictated Reimbursement dictated by YOU!by YOU!
Morbidity Morbidity –– potential potential mortalitymortality
No real morbidity, NO No real morbidity, NO mortalitymortality
Little to no Little to no ““Rules of Rules of examexam”” –– professional professional judgmentjudgment
““Rules of examRules of exam”” cookbook cookbook and dictated by TOBand dictated by TOB
Reimbursement Reimbursement diagnosis or symptom diagnosis or symptom drivendriven
Reimbursement requires Reimbursement requires no driverno driver
MEDICAL CAREMEDICAL CAREWELLNESS CAREWELLNESS CARE
Wellness Care vs. Medical CareWellness Care vs. Medical Care
Reimbursement dictated Reimbursement dictated by by payorspayors
Reimbursement dictated Reimbursement dictated by YOU!by YOU!
Morbidity Morbidity –– potential potential mortalitymortality
No real morbidity, NO No real morbidity, NO mortalitymortality
Little to no Little to no ““Rules of Rules of examexam”” –– professional professional judgmentjudgment
““Rules of examRules of exam””cookbook and dictated cookbook and dictated by TOBby TOB
Reimbursement Reimbursement diagnosis or symptom diagnosis or symptom drivendriven
Reimbursement requires Reimbursement requires no driverno driver
MEDICAL CAREMEDICAL CAREWELLNESS CAREWELLNESS CARE
Wellness Care vs. Medical CareWellness Care vs. Medical Care
Reimbursement dictated Reimbursement dictated by by payorspayors
Reimbursement dictated Reimbursement dictated by YOU!by YOU!
Morbidity Morbidity –– potential potential mortalitymortality
No real morbidity, NO No real morbidity, NO mortalitymortality
Little to no Little to no ““Rules of Rules of examexam”” –– professional professional judgmentjudgment
““Rules of examRules of exam””cookbook and dictated cookbook and dictated by TOBby TOB
Reimbursement Reimbursement diagnosis or symptom diagnosis or symptom drivendriven
Reimbursement requires Reimbursement requires no driverno driver
MEDICAL CAREMEDICAL CAREWELLNESS CAREWELLNESS CARE
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Back to BasicsBack to BasicsPayorsPayors
There are five There are five payorspayors of eye careof eye care
1.1. PatientPatient2.2. Vision InsuranceVision Insurance3.3. Medical InsuranceMedical Insurance4.4. MedicareMedicare5.5. MedicaidMedicaid
PayorsPayorsPatientPatient
No rules apply!!!No rules apply!!!Can bill wellness or medical careCan bill wellness or medical careReimbursement is solely based on what Reimbursement is solely based on what youyou’’re willing to chargere willing to chargePaid todayPaid today
PayorsPayorsVision InsuranceVision Insurance
1.1. Few rules that govern the examFew rules that govern the exam2.2. DoesnDoesn’’t require a medical complaintt require a medical complaint3.3. Can use as a gateway to medical careCan use as a gateway to medical care4.4. Carries with it some amount of patient Carries with it some amount of patient
expectation thoughexpectation though
PayorsPayorsMedical InsuranceMedical Insurance
1.1. Some rules apply for covered benefitsSome rules apply for covered benefits2.2. DoesnDoesn’’t require a medical complaint, t require a medical complaint,
only a medical problemonly a medical problem3.3. Must have a medical diagnosis to justify Must have a medical diagnosis to justify
the exam and/or proceduresthe exam and/or procedures4.4. May have allowances for routine eye May have allowances for routine eye
care INCLUDING materialscare INCLUDING materials
PayorsPayorsMedicare onlyMedicare only
1.1. Lots of rules apply for covered benefitsLots of rules apply for covered benefits2.2. Must have a medical complaint*Must have a medical complaint*3.3. Must have a medical diagnosis to justify Must have a medical diagnosis to justify
the medical complaint to bill a medical the medical complaint to bill a medical exam and/or proceduresexam and/or procedures
4.4. Never covers routine vision exam or Never covers routine vision exam or refractionrefraction
What is a Medical Complaint?What is a Medical Complaint?
1.1. Medical symptom Medical symptom oror2.2. Physician directedPhysician directed followfollow--up based on up based on
a prior condition diagnosed ora prior condition diagnosed or3.3. History of eye problem diagnosed before History of eye problem diagnosed before
you and you and state in record that patient state in record that patient wants condition evaluatedwants condition evaluated oror
4.4. Few systemic problems Few systemic problems –– diabetes, high diabetes, high risk medication use, headacherisk medication use, headache
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What is a Medical Symptom?What is a Medical Symptom?
Almost anything other than blurred vision Almost anything other than blurred vision and sometimes that tooand sometimes that tooNOT a routine eye exam or yearly NOT a routine eye exam or yearly checkup or other such wordingcheckup or other such wordingCommonly overlooked symptoms:Commonly overlooked symptoms:
Floaters, glare, difficulty with night driving, Floaters, glare, difficulty with night driving, growths on eyes, fluctuating vision, itchy eyes, growths on eyes, fluctuating vision, itchy eyes, burning eyes, watery eyesburning eyes, watery eyes
PayorsPayorsMedicaidMedicaid
1.1. Follows most rules that apply to Follows most rules that apply to Medicare covered benefits but has some Medicare covered benefits but has some unique rules toounique rules too
2.2. Has allowances for medical care and Has allowances for medical care and routine eye care including materialsroutine eye care including materials
3.3. Medical billing doesnMedical billing doesn’’t require a t require a medical complaint, only a medical medical complaint, only a medical problemproblem
4.4. Can now bill for a separate refraction!Can now bill for a separate refraction!
Unique Unique PayorPayor RulesRules
Only way to find some of these rules out is Only way to find some of these rules out is to look it up, bill and see, or give up.to look it up, bill and see, or give up.
Medicare/Medicaid have Medicare/Medicaid have LCDsLCDs..Blue Cross Blue Shield does not pay for Blue Cross Blue Shield does not pay for corneal topography for any diagnosis.corneal topography for any diagnosis.VSP uses 92000 codes for wellness examsVSP uses 92000 codes for wellness exams
Local Coverage Determination (LCD)Local Coverage Determination (LCD)
Determined by the carrier (Trailblazer) and Determined by the carrier (Trailblazer) and change oftenchange oftenTypically limited to Medicare and Medicaid Typically limited to Medicare and Medicaid (although others may mimic)(although others may mimic)You MUST know and follow these limiting You MUST know and follow these limiting diagnosis rules or get denieddiagnosis rules or get denied
LCD ExamplesLCD Examples
““WOULD NOT EXPECTWOULD NOT EXPECT”” to perform to perform scanning laser at the same visit with visual scanning laser at the same visit with visual fields, fields, fundusfundus photography, Bphotography, B--scan or scan or extended ophthalmoscopyextended ophthalmoscopy
CANNOT perform more than one retinal or CANNOT perform more than one retinal or external photo at a given examinationexternal photo at a given examination
LCD ExamplesLCD Examples
Photos cannot just document existence of Photos cannot just document existence of a conditiona condition……must be used in the must be used in the diagnostic and treatment decision making diagnostic and treatment decision making processprocess
Repeat Repeat fundusfundus photos only used to photos only used to document change or progressiondocument change or progression
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Websites for your Favorites ListWebsites for your Favorites List
www.cms.hhs.govwww.cms.hhs.gov(Medicare)(Medicare)
http://www.cms.hhs.gov/NationalMedicareYouTrainhttp://www.cms.hhs.gov/NationalMedicareYouTrain(Learning Center)(Learning Center)
www.trailblazerhealth.comwww.trailblazerhealth.com(Carrier)(Carrier)
www.pgba.comwww.pgba.com(Palmetto)(Palmetto)
(commercial (commercial payorspayors usually have informational websites too)usually have informational websites too)
Numbers InvolvedNumbers Involved
CPT CPT –– Current Procedural Current Procedural TerminologyTerminology
What procedures you didWhat procedures you did
ICD 9 ICD 9 –– International Classification International Classification of Diseases, version 9of Diseases, version 9
What diseases you foundWhat diseases you found
CPT CodesCPT Codes99000 99000 Evaluation/Management ServicesEvaluation/Management Services92000 92000 General Ophthalmological ServicesGeneral Ophthalmological Services92000 92000 Diagnostic TestsDiagnostic Tests80000 80000 Laboratory TestsLaboratory Tests70000 70000 Radiology TestsRadiology Tests60000 60000 Surgical ProceduresSurgical Procedures
CPT Examination CodesCPT Examination Codes
Evaluation and Management Codes:Evaluation and Management Codes:New Pt: 992New Pt: 9920011, 992, 9920022, 992, 9920033, 992, 9920044, 992, 9920055Established Pt: 992Established Pt: 9921111, 992, 9921122, 992, 9921133, 992, 9921144, 992, 9921155
Ophthalmological Codes:Ophthalmological Codes:New Pt: 920New Pt: 9200022, 920, 9200044Established Pt: 920Established Pt: 9201122, 920, 9201144
44thth digit differentiates if itdigit differentiates if it’’s a new or established s a new or established ptpt55thth digit differentiates the level of the examdigit differentiates the level of the exam
ICD 9 CodesICD 9 Codes
Dry Eye SyndromeDry Eye Syndrome 375.15375.15CataractCataract 366.16366.16Type 2 DiabetesType 2 Diabetes 250.00250.00FloatersFloaters 379.24379.24
References:References:ICD 9 CM, 2008 office ed. ICD 9 CM, 2008 office ed. ©©2007. PMIC.2007. PMIC.EHR, EHR, EyeCOREyeCORhttp://icd9cm.chrisendres.com/http://icd9cm.chrisendres.com/
Coding and BillingCoding and Billing
Code to highest level of specificity Code to highest level of specificity ““best fitbest fit””
Use eye codes, not systemicUse eye codes, not systemicfew exceptions few exceptions –– headache, diabetes, etcheadache, diabetes, etc
Use the 5 digit version of the codeUse the 5 digit version of the codeOnly code what justifies the proceduresOnly code what justifies the procedures
If you diagnosis it, then you must treat it; but If you diagnosis it, then you must treat it; but you you dondon’’t have to code for it!t have to code for it!
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Coding and BillingCoding and Billing
There are many ways/styles of billing the There are many ways/styles of billing the exact same patient encounterexact same patient encounter
No one way is right/wrong or appropriate No one way is right/wrong or appropriate for every given patient encounterfor every given patient encounter
Legal to use different styles based on the Legal to use different styles based on the patient encounterpatient encounter
Styles of BillingStyles of Billing
Manage patient expectationsManage patient expectations
Manage office efficiencyManage office efficiency
Reimbursed for vision careReimbursed for vision care
Reimbursed for medical careReimbursed for medical care
General TipsGeneral Tips
Find out medical benefits before the examFind out medical benefits before the examSpecialist copay or CoinsuranceSpecialist copay or CoinsuranceProcedural copay (if there is one)Procedural copay (if there is one)DeductibleDeductible
How much they have metHow much they have met
Routine eye care allowanceRoutine eye care allowance
If Medicare patient, get a medical symptom!If Medicare patient, get a medical symptom!
Case ExamplesCase Examples
For medical exams, 92000 codes are the For medical exams, 92000 codes are the only examples used hereonly examples used here
For vision exams, S0620 code is usedFor vision exams, S0620 code is used
Example Example HCFAsHCFAs used here only site the used here only site the medical billingmedical billing
Health Health Insurance Insurance
Claim FormClaim Form(CMS 1500)(CMS 1500)
Case #1Case #1
48yo diabetic female presents with a 48yo diabetic female presents with a gradual decrease in her distance and near gradual decrease in her distance and near vision with her progressive lenses. She vision with her progressive lenses. She reports good control of her diabetes, but reports good control of her diabetes, but does notice her vision changes depending does notice her vision changes depending on her control. She has both vision and on her control. She has both vision and medical insurance.medical insurance.
Medical symptom?
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Medical RecordMedical Record
Refraction: Refraction: --2.00DS with 20/20 OU2.00DS with 20/20 OUSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--)DR)DR
Diagnoses:Diagnoses:Diabetes with ophthalmic manifestations Diabetes with ophthalmic manifestations (250.50)(250.50)Myopia (367.10)Myopia (367.10)
Billing Scenario #1Billing Scenario #1
Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using myopia (367.10) to vision insurancemyopia (367.10) to vision insurance
Collect vision insurance copayCollect vision insurance copay
Managed patient expectations
Not reimbursed for medical care
Billing Scenario #2Billing Scenario #2Bill a comprehensive medical exam (92004) Bill a comprehensive medical exam (92004) using diabetes with ophthalmic manifestations using diabetes with ophthalmic manifestations (250.50) to medical insurance(250.50) to medical insurance
Collect the medical insurance copay or monies going Collect the medical insurance copay or monies going toward deductibletoward deductible
Reimbursed for medical care
Not reimbursed for vision carePatient may question why vision insurance isn’t
being used and bill is higher
Billing Scenario #3Billing Scenario #3Bill a wellness vision exam (S0620) on initial visit Bill a wellness vision exam (S0620) on initial visit to vision insuranceto vision insurance
Collect vision insurance copayCollect vision insurance copay
Bill an intermediate medical exam (92012) on Bill an intermediate medical exam (92012) on followfollow--up visit using diabetes with ophthalmic up visit using diabetes with ophthalmic manifestations (250.50) to medical insurancemanifestations (250.50) to medical insuranceBill extended ophthalmoscopy (92225Bill extended ophthalmoscopy (92225--RT/LT) RT/LT) using diabetes with ophthalmic manifestations using diabetes with ophthalmic manifestations (250.50) to medical insurance(250.50) to medical insurance
Collect medical insurance copay or monies going Collect medical insurance copay or monies going toward deductibletoward deductible
Billing Scenario #3Billing Scenario #3
Reimbursed for all care delivered
Took 2 visits = more timePatient might not come back for 2nd
exam
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Case #2Case #2
67yo male presents with a decrease in his 67yo male presents with a decrease in his distance and near vision with his distance and near vision with his progressive lenses. He also complains of progressive lenses. He also complains of an inability to drive in the dark due to his an inability to drive in the dark due to his bad night vision. He has Medicare only.bad night vision. He has Medicare only.
Medical symptom?
Medical RecordMedical Record
Refraction: +2.00DS with 20/30 OD, OSRefraction: +2.00DS with 20/30 OD, OSSLE findings: 2+ NS cataracts OUSLE findings: 2+ NS cataracts OUDFE findings: unremarkable OUDFE findings: unremarkable OU
Diagnoses:Diagnoses:Cataracts, nuclear sclerosis (366.16)Cataracts, nuclear sclerosis (366.16)Hyperopia (367.10)Hyperopia (367.10)
Billing Scenario #1Billing Scenario #1Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using hyperopiahyperopia (367.00) to patient(367.00) to patient
Collect UCR from patientCollect UCR from patient
Managed patient expectationsGot paid today
Not reimbursed for medical care and there was even decreased vision
Might have been able to save patient money by using his Medicare and you could had higher reimbursement
Billing Scenario #2Billing Scenario #2
Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using nuclear sclerosis cataracts (92004) using nuclear sclerosis cataracts (366.16) to Medicare(366.16) to Medicare
Collect the appropriate monies based on Collect the appropriate monies based on unmet Medicare deductibleunmet Medicare deductible
Bill a refraction (92015) using Bill a refraction (92015) using hyperopiahyperopia(367.00) to the patient(367.00) to the patient
Collect UCR from patientCollect UCR from patient
Billing Scenario #2Billing Scenario #2
Reimbursed for medical and vision care in one visitMay have saved the patient money depending
on Medicare deductible status
Patient may question why using Medicare, but maybe the conversation is easy due to the decreased vision aspect
Patient may also question why he has to pay for the refraction
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Case #3Case #3
29yo male presents with complaints of 29yo male presents with complaints of occasional flashes ever since a car occasional flashes ever since a car accident last week. No other real vision accident last week. No other real vision complaints that affect him daily. He has complaints that affect him daily. He has vision and medical insurance.vision and medical insurance.
Medical symptom?
Medical RecordMedical Record
Refraction: Refraction: --0.25DS with 20/20 OD, OS0.25DS with 20/20 OD, OSSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--))RDsRDs
Diagnoses:Diagnoses:PhotopsiaPhotopsia (368.15)(368.15)Myopia (367.10)Myopia (367.10)
Plan: RTC 1wk for Plan: RTC 1wk for f/uf/u
Billing Scenario #1Billing Scenario #1
Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using myopia (367.10) to vision insurancemyopia (367.10) to vision insurance
Collect vision insurance copayCollect vision insurance copay
Managed patient expectations
Not reimbursed for medical care and there is a real liability for a detachment
Billing Scenario #2Billing Scenario #2
Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using (92004) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance
Collect the medical insurance copay or monies Collect the medical insurance copay or monies going toward deductiblegoing toward deductible
Choose not to bill refraction since patient Choose not to bill refraction since patient didndidn’’t really need glasses nor the potential t really need glasses nor the potential extended ophthalmoscopyextended ophthalmoscopy
Billing Scenario #2Billing Scenario #2
Reimbursed for the medical care and higher reimbursement
Patient may question why you’re not using vision insurance, but maybe the conversation is easy due to the potential detachment issue
Could have billed extended ophthalmoscopy for higher reimbursement
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Billing Scenario #3Billing Scenario #3
Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using (92004) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insuranceBill extended ophthalmoscopy (92225Bill extended ophthalmoscopy (92225--RT/LT) using RT/LT) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance
Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Billing Scenario #3Billing Scenario #3
Reimbursed for all the medical care and highest reimbursement
Patient may question why they have to pay all these charges instead of using the vision insurance and even more now for the extra test
Case #3 Case #3 –– Return VisitReturn Visit
Same patient returns 1wk later because Same patient returns 1wk later because you wanted to followyou wanted to follow--up on the continued up on the continued flashes. He has not seen any flashes flashes. He has not seen any flashes since his last visit.since his last visit.
Medical symptom?
Medical RecordMedical Record
Vision: 20/25 OUVision: 20/25 OUSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--))RDsRDs
Diagnoses:Diagnoses:PhotopsiaPhotopsia (368.15)(368.15)
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Billing Scenario #1Billing Scenario #1
No charge visit No charge visit –– didndidn’’t bill patientt bill patient
Made patient happy without a bill
Didn’t get reimbursed for continued medical care
Billing Scenario #2Billing Scenario #2
Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using using photopsiaphotopsia (368.15) to medical (368.15) to medical insuranceinsurance
Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Still chose not to bill extended Still chose not to bill extended ophthalmoscopyophthalmoscopy
Billing Scenario #3Billing Scenario #3
Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using using photopsiaphotopsia (368.15) to medical (368.15) to medical insuranceinsuranceBill subsequent extended ophthalmoscopy Bill subsequent extended ophthalmoscopy (92226(92226--RT/LT) using RT/LT) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance
Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Billing Scenario #3Billing Scenario #3
Reimbursed for all the medical care and highest reimbursement
Patient may question why they have to pay again for the same problem
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Case #4Case #4
52yo female presents with dry eye 52yo female presents with dry eye complaints. Its been oncomplaints. Its been on--going for years going for years without much help from artificial tear use. without much help from artificial tear use. Also feels like her vision has been affected Also feels like her vision has been affected by her dry eyes. She has both vision and by her dry eyes. She has both vision and medical insurance.medical insurance.
Medical symptom?
Medical RecordMedical Record
Refraction: +2.50DS with 20/25 OURefraction: +2.50DS with 20/25 OUSLE findings: 2+ diffuse SPK OU, 1+ SLE findings: 2+ diffuse SPK OU, 1+ diffuse conjunctival hyperemia OUdiffuse conjunctival hyperemia OUDFE findings: unremarkable OUDFE findings: unremarkable OU
Diagnoses:Diagnoses:Dry Eye (375.15) causing decreased vision Dry Eye (375.15) causing decreased vision
Plan: RTC 2wk for followPlan: RTC 2wk for follow--upup
Billing Scenario #1Billing Scenario #1
Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using myopia (367.10) to vision insurancemyopia (367.10) to vision insurance
Collect vision insurance copayCollect vision insurance copay
Managed patient expectations
Not reimbursed for medical care of dry eyes and there was decreased vision
Billing Scenario #2Billing Scenario #2
Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using dry eye (375.15) to medical (92004) using dry eye (375.15) to medical insuranceinsurance
Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Waive the refraction feeWaive the refraction fee
Billing Scenario #2Billing Scenario #2
Got reimbursed for the medical care delivered and waived the refraction fee to make life easier
Patient may question why their vision insurance isn’t being used and they have a higher copay
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Case #4 Case #4 –– Return VisitReturn Visit
Same patient returns 2wks later with Same patient returns 2wks later with improved symptoms, but still feeling like improved symptoms, but still feeling like eyes are dry.eyes are dry.
Medical symptom?
Billing Scenario #1Billing Scenario #1Since you billed the medical exam initially, bill a Since you billed the medical exam initially, bill a wellness vision exam (S0620) using wellness vision exam (S0620) using hyperopiahyperopia(367.10) to vision insurance(367.10) to vision insurance
Collect the vision insurance copayCollect the vision insurance copay
Patient understands that initially something was wrong, but now that everything is okay is getting to use vision insurance and pay less
Not reimbursed for medical care of dry eyes
Billing Scenario #2Billing Scenario #2
Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using dry eye (375.15) to medical using dry eye (375.15) to medical insuranceinsurance
Decide not to collect the medical insurance Decide not to collect the medical insurance copaycopay……CANNOT DO THIS!!!CANNOT DO THIS!!!Must collect the medical insurance copay or Must collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Billing Scenario #3Billing Scenario #3
Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using dry eye (375.15) to medical using dry eye (375.15) to medical insuranceinsuranceBill for Bill for punctalpunctal plugs (68761plugs (68761--E2,E4)E2,E4)
Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible
Billing Scenario #3Billing Scenario #3
Get higher reimbursement and will help maintain patient’s eye health for longer period of time with plugs
Patient might have a problem with the costs involved in the medical care of dry eys
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How to Collect from MedicareHow to Collect from Medicare
Know MedicareKnow Medicare’’s fee schedules fee scheduleCannot charge Medicare more for covered Cannot charge Medicare more for covered service than private pay patientservice than private pay patient
How to Charge:How to Charge:2011 Annual Deductible ($162) then,2011 Annual Deductible ($162) then,Medicare pays 80% of covered servicesMedicare pays 80% of covered servicesPatient pays 20% of covered services and Patient pays 20% of covered services and 100% for any non100% for any non--covered servicecovered service
Example ChargesExample Charges
CPTsCPTs::92004 (exam)92004 (exam)9222592225--RT (ext RT (ext ophthalophthal))9222592225--LT (ext LT (ext ophthalophthal))92015 (refraction)92015 (refraction)
Total =Total =
Charges:Charges:$149$149$30$30$30$30$25$25$234$234
What are the covered services under Medicare?
Covered Services Total = $209Non-Covered Services Total = $25
Annual Deductible Met Annual Deductible Met –– NoNo
Covered Services:Covered Services:Patient Pays:Patient Pays:
$209 $209 -- $162 (deductible) = $47$162 (deductible) = $4720% of $47 = $9.4020% of $47 = $9.40$162 + $9.40 = $171.40$162 + $9.40 = $171.40
Medicare Pays:Medicare Pays:80% of $47 = $37.6080% of $47 = $37.60
NonNon--covered Services:covered Services:Patient Pays:Patient Pays:
$25 + $171.40 = $196.40$25 + $171.40 = $196.40
Annual Deductible Met Annual Deductible Met –– YesYes
Covered Services:Covered Services:Patient Pays:Patient Pays:
20% of $209 = $41.8020% of $209 = $41.80
Medicare Pays:Medicare Pays:80% of $209 = $167.2080% of $209 = $167.20
NonNon--covered Services:covered Services:Patient Pays:Patient Pays:
$25 + $41.80 = $66.80$25 + $41.80 = $66.80
Thank youThank you
Questions?Questions?