This article is more than 5 years old. Information may no longer be current.
Some office visits can be billed with minor surgical procedures
Click Here to Manage Email Alerts
|
|
Doctors of optometry have been involved in providing surgical procedures for managing eye conditions for at least 2 decades. Even before state laws were changed to acknowledge doctors’ activities, optometrists were removing foreign material from the conjunctival sac, lids and corneas; epilating lashes scratching patients’ corneas; dilating and irrigating lacrimal puncta; and providing a few other surgical procedures.
In those early days, it would have been most common for the doctor to diagnose the need for the procedure during an office visit, conduct the procedure and dismiss the patient, possibly charging only for the office visit. This behavior permitted the doctor to take care of the patient’s discomfort without the need for a return visit to the office or a visit to another eye care provider. The patients were grateful; employers appreciated the decrease in down time, as the patient returned to work quickly; and insurers benefited unwittingly, as they were saved the expense of a visit to the emergency room where such conditions were often handled.
ODs now reimbursed for surgical procedures
Times have changed. Now, with some variation, doctors of optometry in all 50 states provide surgical services daily in their practices. After carefully recording the patient’s signs and symptoms, the results of diagnostic testing and the procedures themselves in the patient’s record, they then report the services to the patient and the patient’s insurance company or other payer using the diagnostic codes of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the procedure codes from Current Procedural Terminology (CPT).
Because optometrists are now providing surgical services more frequently, more attention has been paid to the definitions of CPT relative to the procedures and to the payers’ rules affecting payment for the services. It is important that doctors and staff understand the rules to be sure that the insurance company is following the rules and that patients are getting their full insurance benefit.
Most importantly, the rules for surgical procedures follow the guidelines for all medical services. The doctor interviews the patient carefully to determine the reason for the visit, designs the physical examination to identify any conditions that require care and prescribes the course of action necessary to resolve the conditions. Once the surgical procedure is done, it is a simple matter of choosing the codes and completing the route slip and the claim form, if insurance coverage is involved.
Coding for office visit, procedure
Possibly the most confusing issue relative to providing minor surgical procedures is whether it is appropriate to charge for an office visit at the same time as the surgical procedure. In general, an office visit should be charged any time the medical record shows that a visit occurred. In other words, the record would include some kind of case history, some kind of physical examination and some kind of medical decision-making, with the choice of the office visit dictated by the level of each of those three components.
 |
With more doctors of optometry providing surgical procedures, the question is asked more frequently, often with unique circumstances reported, prompting us to take another look at the issue. When in doubt, it is always best to turn to the most important reference, CPT. I always recommend that each doctor comply as closely as possible with the rules included there. It is not always perfectly clear, but even if your interpretation differs from the payer’s interpretation, the issue normally can be resolved amicably if both doctor and insurer are referring to the same source.
Most of the surgical procedures provided by optometrists are known as “minor surgical procedures.” This set of services used to have a 10-day global period, meaning that it would have been improper to bill an office visit on the day of the procedure or any office visits during the 10 days following the procedure. That rule changed a few years ago, so that now it is acceptable to bill for an office visit following a minor surgical procedure, even the first day postoperatively.
Unfortunately, however, there remains widespread confusion as to whether it is proper to bill for an office visit on the same day and in addition to a surgical procedure. See the box on page 15 for the CPT guidelines on this.
Although the statement from the CPT may not be as clear as we would like, it is important that each doctor reviews the statement to decide which office visits related to surgical procedures can be billed and which must be considered part of the procedure itself. If a payer questions your charges, you want to be able to have a good, well thought out answer.
The second bullet point clearly states that each surgical procedure includes an “E/M encounter” – an office visit – either on the day before the procedure or the day of the procedure. In my opinion, the same statement infers that the office visit at which the decision for the procedure is made, the one before the procedure is done, can be billed.
Example: glaucoma evaluation
Consider this example of a patient who comes in for a glaucoma evaluation. The doctor performs a slit lamp examination, which reveals several lashes scratching the cornea of the right eye. The doctor completes the evaluation, explains the need for epilation, and the patient decides to have the lashes removed during the same visit.
The doctor epilates the lashes and bills for the office visit, choosing the code based upon the medical record’s history, examination and medical decision-making and using the appropriate diagnosis code for the patient’s glaucoma. The modifier –25 would be placed on the office visit code to indicate to the payer that the visit is unrelated to the surgical procedure. In addition, the epilation would be billed with its own surgical code, 67820, without a modifier, and with the diagnosis code for trichiasis.
Example: foreign body
Consider a second example of a patient who enters the office complaining of a sore left eye. The staff and doctor conduct a thorough case history, during which the patient reports discomfort for several days, traced back to his changing the muffler on his car. The slit lamp examination shows a metallic foreign body, which the doctor recommends be removed immediately. The patient concurs.
The medical record would include the case history, the elements of the physical examination completed by the doctor and the medical decision-making. This includes the diagnosis of eye pain, corneal foreign body and the management options – to remove the foreign body and the small rust ring at the slit lamp, instill antibiotics and see the patient in 24 hours or as needed.
The office visit code would be chosen based on the key elements of history, examination and medical decision making. It would be billed with eye pain (379.91) as the diagnosis and again with the -25 modifier to help the payer understand that the visit is separately identifiable, relative to the surgical procedure. The procedure would be billed with its own code, 65222, with the corneal foreign body (930.0) as the diagnosis. No modifier would need to be added to the 65222.
In either of these examples, epilation or removal of foreign body, it would be perfectly appropriate to bill for visits on the days following the date of the procedure, beginning first day postoperatively. As always, the choice of code for such follow-up visits is based on the content of the medical record, compared with the appropriate CPT definitions.
Global fee for punctal occlusion
Closure of punctum, by plug, 68761, seems to be unique among minor surgical procedures in that many payers are continuing to apply the 10-day global fee period following the use of this code. For example, if a temporary plug is inserted, it is important to wait beyond 10 days (the assumed global period) before inserting a permanent plug. This is normally not an issue, as doctors feel it is important to wait a few days to assess the effect of the plug before inserting the permanent plug anyway.
CPT a key resource
CPT remains the key resource for understanding which codes to use for which services and procedures. Doctors and staff who know and understand it well will usually do an excellent job of communicating with payers and sustaining their choices of codes, even if reviewed or audited by a payer. No one, including payers’ representatives, can know everything about every code, so CPT is critical in protecting doctors from inappropriate rejections of claims for in-office surgical procedures as well as for all other services.
Costs are involved in following the rules, including about $100/year for appropriate resource materials (Codes for Optometry, American Optometric Association), as well as the time it takes to get to know the resources. However, the results are well worth it. You will not have to work very hard to become as smart as or smarter than the average employee of a health care insurer and to benefit from higher income derived from more accurate coding and fewer headaches from rejected claims.
For more information:References:
- Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board, executive vice president of the Wisconsin Optometric Association and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., PO Box 608, Waupaca, WI 54981; (715) 942-0410; fax: (715) 942-0412; e-mail: Brownlowod@aol.com.
- For more information on the ICD-9-CM, go to www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm.
- For more information on the Current Procedural Terminology, go to www.ama-assn.org/ama/pub/category/3113.html.
- Codes for Optometry is available from the American Optometric Association, (800) 365-2219, Web site: www.aoa.org.