Ophthalmology and Optometry Coding Alert

In Medicare, the computer that reads your claims determines quickly whether a procedure is "medically necessary" by the diagnosis code you link to it. The problem is, carriers have different medical-necessity lists -- the lists of payable diagnoses by procedure. When you read that one diagnosis may support a procedure in one geographical area, you can't assume that the same is true in your geographical area.
 
Should Physicians See Lists?
 
Compliance experts differ on whether a physician should even see the medical-necessity lists. Such lists can be useful to physicians educated on the fraud and abuse issues related to using codes on the list to the exclusion of other, more appropriate codes. If an ophthalmologist knows which diagnosis codes will support a particular procedure and does not understand his or her obligation to select the most appropriate code -- even if it is not on the list -- he or she would likely pick a code from the list that came somewhat close to the real diagnosis.

However, this would leave out the rest of the ICD-9 choices, which might include an even more appropriate (although not necessarily payable) diagnosis. Allowing a physician to use carrier lists of approved diagnosis codes can result in fraud if the process is used for coding a claim to get paid instead of to represent the accurate condition of the patient. The same problem can occur by using commercially sold "code-link" books and programs.

A real danger of using the list of payable diagnosis codes is that the claim may not be supported by the documentation. Also, not every CPT code is covered by a local medical review policy (LMRP) by every carrier. Educate physicians to select the most accurate ICD-9 code for the condition documented in the medical record.

The bottom line: The ophthalmologist, not the coder, must pick the proper diagnosis. The ophthalmologist may respond: "But what if the one I pick doesn't get the claim paid?" If the one you picked is the best code for the status of the patient and it doesn't get paid, the patient must pay. If, however, the practice has had previous denials for that diagnostic code and fails to get an advance beneficiary notice (ABN) signed by the patient for that visit or procedure, the patient can't be billed. When an office knows a service will be denied because the Medicare carrier does not deem that service reasonable and necessary based on that diagnosis, they should have the patient sign an ABN. This is the major reason why the office staff must know which codes are accepted by their carrier for payment.
 
Visual Field Testing for Patients on Steroids
Patients who have lupus or rheumatoid arthritis undergo steroid treatment. The [...]