Академический Документы
Профессиональный Документы
Культура Документы
1
3/12/2018
Financial Disclosure
Joy Woodke, COE, OCS
2
3/12/2018
3
3/12/2018
4
3/12/2018
5
3/12/2018
ESSENTIAL TOPICS
Master the Fundamentals of Retina Coding
6
3/12/2018
Master Modifiers
7
3/12/2018
8
3/12/2018
Master Modifiers
• Modifiers can be appended to
o Office visits
▪ -24, -25, -57
o Diagnostic testing services
▪ -RT, -LT, -TC, -26, -50, -59
o Surgery
▪ -50, -54, -55, -58, -59, -78, -79, -RT, -LT
9
3/12/2018
24 25 57
Significant, separately,
Unrelated evaluation and identifiable evaluation and Decision for
management service (or eye management service (or eye surgery, major
codes) by the same physician codes) by the same physician on procedure
during a postoperative period the same day of the procedure or
other services
10
3/12/2018
58 78 79
1. Lesser to greater Unplanned return to Unrelated procedure
2. Pre-planned and documented as operating room during during the post-op
staged the post-op period period
3. Therapy following a major surgery
UNPLANNED PLANNED OR
PLANNED OR UNPLANNED
UNPLANNED
RELATED
UNRELATED
RELATED
SURGERY
MODIFIERS
11
3/12/2018
Modifier Mayhem
• Do not append surgery modifiers to testing services
92134-79
92235-58
67108-57
99214-LT
12
3/12/2018
A. True
B. False
13
3/12/2018
A. True
B. False
14
3/12/2018
A. 92XXX or 99XXX – 79
B. 92XXX or 99XXX – 24
C. 92XXX or 99XXX – 25
15
3/12/2018
A. 92XXX or 99XXX – 79
B. 92XXX or 99XXX – 24, opposite eye, note: ICD10
C. 92XXX or 99XXX – 25
16
3/12/2018
17
3/12/2018
Modifier Review
• Procedure: 67036-RT
• What modifier should be used?
o-78
o-79
o-58
18
3/12/2018
Modifier Review
• Procedure: 67036-RT
• What modifier should be used?
19
3/12/2018
20
3/12/2018
21
3/12/2018
CCI EDITS =
Same Surgeon
Same Patient
Same Day
Same Session
Same Surgical Site
Note: CCI NOT applicable during global period
22
3/12/2018
23
3/12/2018
24
3/12/2018
25
3/12/2018
26
3/12/2018
• Epiretinal membrane
o H35.372
27
3/12/2018
• Epiretinal membrane
o H35.372
28
3/12/2018
a. 67040-LT
b. 67041-LT
c. 67040-LT, 67041-59-LT
29
3/12/2018
a. 67040-LT
b. 67041-LT
c. 67040-LT, 67041-59-LT
30
3/12/2018
Vitrectomy Surgery
• RVUs:
31
3/12/2018
Global Periods
32
3/12/2018
Global Periods
• The global periods vary by surgery and by insurance carrier
• Medicare 10 day global period = 90 day global period for
some insurance carriers
• How can you confirm the global period?
o RVU / allowable
33
3/12/2018
Global Periods
• Minor procedure
o Global period – 0 or 10 days
o Examples
▪ Repair RD, cryo 67101 10 day global
▪ Intravitreal injection 67028 0 day global
• Major procedure
o Global period – 90 days (Medicaid is often 45-90)
▪ Vitreous tap 67015 90 day global
▪ Repair RD, vx, 67108 90 day global
▪ Laser to rep ret tear 67145 90 day global
34
3/12/2018
35
3/12/2018
25 57
Significant, separately, identifiable
evaluation and management service Decision for surgery,
(or eye codes) by the same physician major procedure
on the same day of the procedure or
other services
36
3/12/2018
CODING UPDATES
Master and Track Changes in Retina Coding
37
3/12/2018
• Commercial payers
o Frequency edits for eye visit codes
38
3/12/2018
ICD-10-CM
39
3/12/2018
ICD-10-CM Updates
• Effective Oct 1, 2017
• 50+ new ICD-10 codes affecting ophthalmology went
into effect Oct. 1, 2017
• The most significant updates expand the codes for vision
rehabilitation and myopic degeneration
o Download copies of decision trees at aao.org/icd10
40
40
3/12/2018
Myopic Degeneration
• January 2017 FDA approved Lucentis as a treatment for
patients with choroidal neovascularization (CNV or
mCNV) resulting from myopic macular degeneration
(MMD)
• No change in the drug units – 5 units
• Documentation should include any residual drug
discarded
41
41
3/12/2018
42
3/12/2018
Myopic Degeneration
• Intravitreal injection of Lucentis for mCNV, right eye
• Correct coding
• 67028-RT
• J2778, 5 units
• Diagnosis: H44.2A1
43
3/12/2018
Insurance Policies
44
3/12/2018
Medicare
• Local Medicare Administrative Contractor (MAC)
o Local Coverage Determination (LCD)
▪ Draft
▪ Active
o Local Coverage Articles
45
3/12/2018
Medicare LCDs
First Coast
• 92134 – SCODI Retina States: PR,
VI, FL
• First Coast – new policy effective 1/2018
o Frequency
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
1 month = 30 days?
▪ Drug related (CQ and/or HCQ) – baseline examination within the first
year and annual follow-up after five years of treatment. Higher-risk,
annual testing may begin immediately (without a 5-year delay).
46
3/12/2018
Medicare LCDs
Palmetto
States: VA,
• 92134 – SCODI Retina NC, WV, SC,
AL, GA, TN
• Palmetto – new policy effective 2/2018
o Frequency
▪ Performed at clinically reasonable intervals
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
Generally not require SCODI more than once per month
▪ Drug related (CQ and/or HCQ) –
Baseline exam first year of commencement if any macular abnormalities
are present
Annual screening beginning at the 5th year of exposure to drug
47
3/12/2018
Medicare LCDs
Novitas States:
• 92134 – SCODI Retina TX, CO, OK,
MS, NM, LA,
AR, DC, PA, DE,
• Novitas – new policy effective 1/2018 NJ, MD
o Frequency
▪ One exam every 2 month manage primary retina conditions
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
1 month = 30 days?
▪ Drug related (CQ and/or HCQ) – baseline examination within the first
year and annual follow-up after five years of treatment. Higher-risk,
annual testing may begin immediately (without a 5-year delay).
48
3/12/2018
Medicare LCDs
CGS States:
• 92134 – SCODI Retina OH, KY
49
3/12/2018
Medicare LCDs
NGS States:
VT, ME, NH, NY,
• 92134 – SCODI Retina MA, RI, CT, MN,
WI, IL
• NGS – new policy effective 10/2017
o No frequency language
o Limitations of coverage
▪ Absence of an indication
▪ Screening
50
3/12/2018
Medicare LCDs
Noridian States:
• 92134 – SCODI Retina UT, AK, WA, AZ,
ND, SD, OR,
• Noridian – new policy effective 10/2017 MT, ID, WY, NV,
GU, HI, CA
o Intraocular Avastin
o Frequency
o 92134 is appropriate at 4-6 week intervals
• Cahaba – no policies
o Transitioned to Palmetto, 2/2018
51
3/12/2018
Medicare LCDs
WPS States:
• 92134 – SCODI Retina IN, MI, KS,
NE, MO, IA
• WPS – new policy effective 9/2017
o Frequency
▪ One exam every 2 month manage primary retina conditions
▪ Active treatment (AMD, CNV, DR, ME) – may be allowed one (1)
scan per month will be considered medically reasonable.
▪ Rapid clinical changes requiring therapy and follow-up (macular hole,
TRD) – monthly
o Limitations of coverage – same day
▪ 92250, 92225 *, 92226 *, 76512 *
*not CCI bundled with OCT – limitations in LCD. Documentation must justify the procedures
52
3/12/2018
Medicare NCDs
• 67221 – PDT
o MACs - No active LCDs
o Active NCD – 80.3.1
▪ Predominately classic subfoveal choroidal neovascularization (CNV)
lesions (where the area of classic CNV occupies ≥ 50% of the area of
the entire lesion) at the initial visit as determined by a fluorescein
angiogram (FA).
3 months prior to treatment
▪ Subsequent follow-up visits require either an optical coherence
tomography (effective April 3, 2013) or an FA (effective April 1, 2004)
to access treatment response.
53
3/12/2018
Commercial Carriers
• Aetna policy
o Nd: YAG laser
o Laser vitreolysis for treatment of vitreous degeneration and
vitreous floaters
▪ Experimental and investigational
54
3/12/2018
Audits
55
3/12/2018
Audits
56
3/12/2018
57
3/12/2018
Audits
• TPE: Targeted Probe and Educate
o MAC audits
▪ Three rounds with education
▪ Continue with high denial rates
extrapolation,
referral to the Zone Program Integrity Contractor (ZPIC) or Unified
Program Integrity Contractor (UPIC),
referral to the RAC,
100% pre-pay review, etc.
58
3/12/2018
Audits
• TPE: Targeted Probe and Educate
o Targets
▪ Subsequent hospital care
▪ Emergency room visits
▪ Subsequent nursing facility care
▪ Correct place of service
59
3/12/2018
60
60
3/12/2018
61
61
3/12/2018
Audits
• Supplemental Medical Review Contractor
(SMRC)
o Contractor – StrategicHealthSolutions, LLC
o Targeted areas
▪ Outpatient drug units
▪ Incorrect place of service
▪ Delegated testing services
Orders
62
3/12/2018
Audits
• Comprehensive Error Rate Testing (CERT)
o Contractor – AdvanceMed
o Request for medical records
o Meet the deadline!
63
3/12/2018
Audits
• Recovery Audits (RA)
o Automated audits
▪ Driven by data
o Complex review
▪ Submit documentation
64
3/12/2018
Audits
• Recovery Audits (RA)
o Automated audits – few examples
▪ Injections sooner than 28 days for all anti-VEGF drugs
Including Avastin
Medicare leeway is 25 days
▪ CPT code 67228 Treatment of extensive or progressive retinopathy
(eg, diabetic retinopathy) billed more than once per eye during the
global period
Note for CMS now a 10-day global period
Recovery auditor may not be aware
Check your own performance for past 12 months
65
3/12/2018
66
3/12/2018
67
3/12/2018
68
3/12/2018
69
3/12/2018
70
3/12/2018
71
3/12/2018
72
3/12/2018
73
3/12/2018
74
3/12/2018
75
3/12/2018
76
3/12/2018
77
3/12/2018
78
3/12/2018
79