coding strategies

Billing for Services: The Really Valuable Part of What We Do

BY CLARKE D. NEWMAN, OD, FAAO

If you get invited to play racquetball, there is no shame in playing by the racquetball rules — it is expected. In the game of third party reimbursements, we are presented with a set of rules, and we should feel no shame in playing by those rules.

The rules are that we get paid for performing medically necessary tests and procedures. Therefore, it's important for us to have the instruments needed to perform the appropriate tests as well as to perform those tests appropriately and get paid appropriately. There is no shame in doing that ethically.

You might argue, rightfully, that the system is flawed, expensive, inefficient and preys on the poor health of our patients instead of promoting good health. We can have a public policy debate on healthcare delivery systems all day long, and I welcome that debate. Our country needs it.

However, until that day we must effectively play the game that we've been asked to play. I editorialize here because many of us are uncomfortable billing for these services, and that is like playing racquetball and feeling uncomfortable with the fact that the court is 40 feet long.

Using Service Codes

Last month, we spoke about consultations. This month, we will discuss service codes: The E/M codes, Levels 1 through 5, new and established, and the General Ophthalmologic codes, Intermediate and Comprehensive, new and established.

It's important for you to read the plain language of each of these codes so that you know which codes to use in which situations and what the documentation requirements are for each. You should read these codes and any additional information each year. In other words, you need to buy the CPT and ICD9 books every year.

I use the General Ophthalmologic codes for two reasons. First, the documentation and the level of care requirements are less demanding for the General Ophthalmologic codes. Second, the CPT preamble concerning the 9231× contact lens fitting codes instructs us to use these codes for follow ups.

Regarding new patients, a patient is considered new if he has not been seen by you or another doctor in the same specialty in the same practice in the previous three years.

The other service codes that can be used with patients needing medically necessary contact lenses are: Refraction (92015), Corneal Topography (92025), External Ocular Photography (92285), Specular Microscopy (92286), Aberrometry (92499), Anterior Segment SLO (92499) and Corneal Pachymetry (76514).

For procedures that use the Unlisted Ophthalmological Code (92499), a Letter of Medical Necessity is usually required and should be sent regardless. Also, check the value of refraction with the various companies. You'll be surprised to find how much more the insurance industry values refraction than we do. You may be leaving money on the table.

Finally, you should know which codes are unilateral and which are bilateral. Billing two topographies, a unilateral code, can result in having both claims rejected. That rejection results in having to pay your staff to sort out the problem and it delays your reimbursements.

You should perform every test that is rational to the care of each patient. Each test should have an indication and an interpretation that affects the treatment plan. If you can document each of these, then you can bill for the service and expect to get paid.

Next month, we'll discuss Contact Lens Service Codes and Material Codes. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery.