Optometry Coding & Billing Alert

Published on Fri Nov 11, 2005 PDF

Plus: You'll be using office visit E/M codes more often beginning Jan. 1, experts say

When a patient comes to you for a second opinion, you easily determine you-ll need 99271-99275. Next year, however, the tide is turning and you will have to forget these codes--instead turning to an office visit or consultation code.

CPT 2006 eliminates codes 99271-99275 (Confirmatory consultation for a new or established patient ...). Starting Jan. 1, you would report either a standard outpatient E/M service (99201-99215) or a consultation (99241-99245)--depending on the circumstances--for so-called -second (or third) opinions.- For a confirmatory consult requested by a patient, it would not be appropriate to report a consultation code starting in 2006, experts say.

-With no confirmatory consults in 2006, you-d treat these services like any other E/M service,- says Suzan Hvizdash, BSJ, CPC, physician education specialist at UPMC Presbyterian-Shadyside in Pittsburgh. If the optometrist receives a request from another physician to examine the patient, renders an opinion and provides a response, -you have an outpatient consult. If the visit doesn't meet the requirements [such as when a patient -self-refers-], you-d charge for a standard office visit.-

Example: A 68-year-old man presents for a second opinion. He has been seeing another doctor for treatment of his glaucoma and monitoring of his cataracts, but he scheduled a visit with you on the recommendation of a friend.

By the new guidelines, you would report an appropriate-level new patient visit (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...).

Ask for an ABN for Second Opinions

Obtain an advance beneficiary notice if the patient is seeking a second opinion for a condition of definitive diagnosis that was not found by a previous physician examination due to the screening nature of the visit. Obtain the ABN before rendering the service. The ABN lets the patient know that he may be responsible for payment if the insurer deems the service unnecessary.

Red flag: You must use form CMS-R-131, the official, CMS-approved ABN form, says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va. Failure to provide a proper ABN in situations when one is required may result in provider liability. Medicare has downloadable forms, in English and Spanish, at www.cms.hhs.gov/medicare/bni.

Payoff: In the past, many payers (including Medicare) have not covered confirmatory consultations because the insurers considered such second opinions a -duplication of services---especially when the second opinions are generated by the patient or patient's family.

Beware: When another physician has already examined the patient and provided an opinion, the payer may deem any attempt to re-examine the patient a duplication of services--even if you bill the care as an office visit or inpatient or outpatient consultation. In this case, obtain the signed ABN from the patient and submit the E/M code with modifier GA (Waiver of liability statement on file).

Apply HCPCS Codes for Ocular Supplies

In 2006, you-ll also say goodbye to some codes dealing with ocular prostheses and spectacle services--but chances are, you won't miss them much.
 
CPT 2006 deletes 92330 (Prescription, fitting and supply of ocular prosthesis [artificial eye], with medical supervision of adaptation) and 92335 (Prescription of ocular prosthesis [artificial eye] and direction of fitting and supply by independent technician, with medical supervision of adaptation). New instructions direct you to report an E/M code or eye code (92002-92014) in place of the deleted codes.

Similarly, CPT 2006 deletes all of the -Supply of Materials- codes (92390-92396), covering the supply of spectacles, contact lenses, low vision aids and ocular prostheses. Revised instructions in the -Contact Lens Services- section read, -The supply of contact lenses may be reported as part of the service of fitting. It may also be reported separately by using the appropriate supply codes.-

Report contact lens supplies for aphakic patients using the HCPCS V25xx codes (for example, V2510, Contact lens, gas permeable, spherical, per lens; or V2522, Contact lens, hydrophilic, bifocal, per lens). Append modifiers RT and LT (Right side and left side) for each eye and modifier KX (Specific required documentation on file) to indicate medical necessity.

Don't code separately for lenses for keratoconic patients. For the fitting, report 92070 (Fitting of contact lens for treatment of disease, including supply of lens).

Don't miss: Because 92070 specifies that supplies are included, you should not code separately for them.