Coding & Reimbursement Lessons Learned in 2023
By Diane E. Zucker, M.Ed., CCS-P
As 2023 comes to an end, let’s take a moment to look at what we have learned over the past year and remember that these lessons will follow us into 2024!
Specific diagnoses is critical to get paid for the care and services you provide. The use of unspecified diagnoses will often result in a claim denial. When performing a procedure that is bilateral, it is best to list each eye separately rather than the bilateral code. When there are contributing issues, such as diabetes or hearing loss, it is also important to use the most specific condition as possible.
The coding for medication monitoring with either oral or drops, would be coded with Z51.81. encounter for therapeutic drug level monitoring and if the medication is a long-term medication with risks the Z79.899 would be appended as well. These codes are specific the prescription drug management and help support higher levels of E/M codes when there is only one condition addressed in an encounter.
When there is a Local Carrier Decision for Medicare (traditional or Managed Care Plans Part C Medicare), the diagnoses listed in these policies are hard and fast. If you have a diagnosis that is not in this list, they rarely consider the situation as meeting their criteria. The LCDs for Medicare LCD in Ohio specific to ophthalmology are with the specific billing and coding identified with the “A” policies:
Blepharoplasty L33944/ A56439
Cataract Extraction L33954/ A56453
Corneal Pachymetry L33999/ A56457
Micro-Invasive Glaucoma (MIGS) L37578/ A56491 (revised 7/2023) Includes T codes.
Ocular Photography External L34393/ A57068
Ophthalmic Angiography L34175/ A57069
Ophthalmic Biometry for Intraocular
Lens Power Calculation L34181/ A57070
Ophthalmology Posterior Segment
Imaging – extended fundus L34399/ A57071
Pan retinal (Scatter) Laser
Photocoagulation L34064/ A56594
Removal of Benign Skin Lesions
(face region included) L34200/ A57044
Scanning Computerized Ophthalmic
Diagnoses Imaging (SCODI) L34061/ A56692
Visual Fields Testing L34394/ A56799
All of these policies are reviewed and updated yearly and the most common reason for update in the policy are new or changed codes in ICD 10.
When you are providing a service for a diagnosis that is not part of the approved list for care, then one needs to have the patient sign an Advanced Beneficiary Notice and submit the claim with the GZ modifier as the last modifier on the service.
One would think that when we use a specific ICD 10 code that is specific to the eye involved in either testing or a surgical procedure, we would not also need a modifier on the CPT code to “re-explain” the location of the concern or issue, however, that is not the case. It is critical that that the modifiers always be appended to the testing or procedure codes:
Modifier RT would be for the right eye.
Modifier LT would be for the left eye.
Modifier -50 would be if the procedure was performed on both the right and left eye.
Specific eyelid modifiers:
Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
These modifiers would be appended to Blepharoplasty procedures (15820, 15821, 15822, 15823) a Chalazion and other specific eyelid family of codes.
When you are providing services with two or more procedure CPT codes, it is critical to use the location modifier as the first modifier and then if there is a conflict within the CCI edits for the second procedure, (always the least expensive) the appropriate X modifier would be used instead of the Modifier 59 is a distinct procedural service that may normally be bundled by CPT code definition or the CCI edits.
XE Separate encounter, for a service that is distinct because it occurred during a separate encounter. This might be a return to the OR the same date as a primary procedure after the patient has gone to recovery.
XS Separate structure is for a service that is distinct because it was performed on a separate organ/structure. In ophthalmology, this would be identified in most cases with a specific eyelid modifier as well.
XP Separate practitioner, as service that is distinct because it was performed by a different provider (not in the same group or cross coverage entity. An example might be a procedure that was performed by an ER physician and now you are involved in care.
XU Unusual non overlapping service that is distinct because it does not overlap the usual components of the main service in this specific case (supported by the operative note).
A few other modifiers that may be needed:
Modifier -76 is a repeat procedure by the same physician (or group) – an example would be a laceration repair that required re-suturing due to a wound dehiscence.
Modifier -77 is a repeat procedure by another physician.
Modifier -78 is a return to the operating room for a related procedure during the global time frame and is diagnoses specific to the case.
Modifier -79 is an unrelated procedure during a global time frame. This procedure is based on the operative note as well as the specific ICD 10 coding involved in both the first procedure and the second procedure.
What should we remember about the changes in E/M for 2023?
With the changes in E/M documentation requirements now based on pertinent history and pertinent exam or total time involved in clinical care of the patient, it is important that the documentation represent the acuity of the problem. As you think about how you document the care provided:
Primary diagnoses managed – is it acute or chronic? What is the potential risk for this condition – vision loss? What is the risk of management – medication, procedures, monitoring? What is your plan for ongoing assessment, testing, visits, and care?
For the prescription management component, remember that the prescription medication should identify the reason for the medication (oral or drops), the method and time of use and the risks and benefits of the medication. At initiation the statement would need to be more robust, but even at renewal this should be restated and part of patient education. Example: Lumigan used nightly, one drop each eye, has limited serious side effects but in rare cases may cause discoloration of vision, night vision issues, and disturbed color perception.
When coding higher levels of E/M services, make sure the primary diagnosis is as specific as possible and if there are secondary diagnoses they are listed as well and within the narrative for the Assessment and Plan you identify how these conditions support or alter your plan of care.
When the care you are providing falls outside of the approved diagnoses or standard of care expectations, have the patient sign an ABN type form. This process helps the patient understand, acknowledge, and agree to payment should the insurance consider this “non covered.”
OOS members have access to complimentary reimbursement assistance.