Ophthalmology and Optometry Coding Alert

Communicate with your doctors to find the most specific code, or risk losing $695 in reimbursement

Your ophthalmologist treats a patient with cataracts. You report CPT code 66852 (Removal of lens material; pars plana approach, with or without vitrectomy) linked to ICD-9 code 366 (Cataract) - but the insurer denies the claim. What happened?

Often, a three-digit diagnosis code does not tell the carrier enough about the patient's illness. When you can make the diagnosis more specific by adding a fourth or fifth digit, experts advise that you should do so.

It's not just Medicare anymore - more payers than ever before are demanding accurate ICD-9 coding. In fact, diagnosis coding
is evolving from a choice to a necessity when filing with some carriers, because they are rejecting claims as "medically unnecessary" at a higher rate than they did a few years ago. And with the Centers for Medicare & Medicaid Services demanding immediate implementation of its new ICD-9 codes from now on, it's plain to see that diagnosis coding isn't getting any less urgent. If you're not taking ICD-9 coding seriously, it's only a matter of time before it affects the practice's bottom line, experts say.

Payers Looking at ICD-9 Codes on Claims

"A lot of us didn't pay attention to ICD-9 coding in the past because Medicare was the only carrier that cared if you used the [most specific] codes," says Victoria Jackson, owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area.

Tip: Before sending out a claim with a three-digit diagnosis code, you should double-check the code, Jackson says. Three-digit diagnosis codes raise the eyebrows of payers, she says, because there are very few ICD-9 codes that aren't at least four digits.

Take the 2-Question Test

To ensure accurate ICD-9 reporting, Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont., asks herself two questions before sending out a claim:

1. Do I have a complete code?
2. Do I have the most specific complete code?

Why are these things important? If the ICD-9 code is not as complete and specific as carrier rules require, the claim may be rejected for lack of medical necessity, Lamb says. You can check that you have the most complete and specific code when looking up the code in the ICD-9 book - if you know what to look for.

Know When Conditions Require 5-Digit Codes

There are certain ICD-9 codes that you must carry out to the fifth digit, so you need to know when a fifth digit is required. One of those codes is 366. In the above example, the ophthalmologist treats a patient with presenile nuclear cataracts. If you link 366 to the CPT code, the claim will be rejected.

Why? You need five digits to indicate the kind of cataract and its location, says Roxanne Oyler, CPC, billing manager for Kentucky Eye Care in Louisville. Adding a fourth digit (0) to 366 narrows the type of cataract down to infantile, juvenile or presenile. The fifth digit specifies where in the eye the cataract has appeared. The code for presenile nuclear cataract would be 366.04 (Infantile, juvenile and presenile cataract; nuclear cataract), Oyler says.

Check Boxes, Then Decide Code Length

"Report the ICD-9 code that provides the highest degree of accuracy and completeness. That 'highest degree' means that you should assign the most precise ICD-9 code that most fully explains the narrative description of the symptom or diagnosis," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, an education specialist in East Orange, N.J.

Is this diagnosis code complete? Rely on your ICD-9 manual's instructions to ensure you're listing complete ICD-9 codes. For example, look to the left of the ICD-9 code for presenile cataract (366.0), and you'll see a box with a check mark and "5th" printed in it. This box indicates that a complete ICD-9 code for this diagnosis must be five digits.

Whenever there is a "5th" box next to an ICD-9 code, it means the most accurate and complete code possible for that diagnosis has five digits - and reporting a code with three or four digits is not acceptable.

'Hey, Doc, Could You Explain This?'

For ICD-9 coding to be accurate and complete, there must be open communication among coders, physicians and other office staff, Baker says.

Coder's challenge: "In order to assign a diagnosis code, you have to make sure you can read the medical record, extract that info out of there, and attach a proper ICD-9 code," Baker says. "Communication is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures."

The physician should always put the diagnosis code on the face sheet, but just in case he doesn't, check all relevant documentation for ICD-9 codes that support the CPT code on the claim.

"If there's any question as to what the diagnosis is, you should query the physician regarding the diagnosis or procedure method," Baker says.

In fact, Baker thinks that even though it is not a Medicare requirement, the physician should always be the one putting the ICD-9 codes on claims, since he is the one who actually evaluates the patient.