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  CODING STRATEGY

SPECIAL OPHTHALMIC SERVICES

TO TEST OR NOT TO TEST; THAT IS THE QUESTION

TECHNOLOGY IS being introduced to the eye care marketplace at a blistering pace. New and better devices have been developed for everything from refracting to imaging of the choroid and beyond. Most of the diagnostic technology developed within the last decade is formally classified by the CPT as “Special Ophthalmological Services.” When ordered and performed, these services have specific rules when performing, recording and coding for them.

According to the CPT 2015 Professional Edition, special ophthalmic tests are contained in a separate section of the CPT and described as:

• Services in which a special evaluation of part of the visual system is made, which goes beyond the service included under general ophthalmological services, or in which special treatment is given.

• Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services.

So, what does that mean? It means that any test that has a specific definition as a separate and distinct procedure, by the virtue of having its own CPT code, is not part of the regular office visit — a general ophthalmologic code (920XX) or an evaluation/management code (992XX) — and may be reported separately (in addition to) the office visit performed on that same day of service.

AN EXAMPLE: OCT

For example, let’s say a patient presents with a chief complaint of distorted or reduced vision in the left eye. During your physical exam, you dilate and look at the macula and note some pigmentary changes and drusen. Based upon these findings, you order an OCT of the retina of the left eye. For this encounter, you would bill the office visit with the appropriate CPT code (920XX or 992XX) and then the OCT of the retina (92314) individually, as they represent distinct and separate components of the total patient encounter. The OCT would be coded the same whether performed or one eye or both, because the definition of the 92134 includes the wording “unilateral or bilateral.”

These tests can be ordered and performed by the physician on the same date of service as the office visit as long as they are performed in accordance with the National Correct Coding Initiative Edits (CCI Edits) and meet all requirements specific to your geographic location for indications of coverage and medical necessity.

Keep in mind, most audit failures for special ophthalmic procedures are generated by not providing adequate or appropriate medical necessity for performing the test in the medical record. In other words, don’t perform the test simply because you want to, or to establish a baseline. You must clearly demonstrate a diagnostic value for ordering and performing the test, and in the future get ready to demonstrate the benefit for the patient and his or her clinical outcome.

MODIFIERS

Special ophthalmic service codes contain two separate and distinct components: (1) the professional component and (2) the technical component. If you perform both the technical and professional components in your practice, don’t separate the code into the individual components; instead, you should always report the code in its entirety.

If performing only a single component of the procedure you would use one of these two modifiers:

• -26 for Professional Component. Certain procedures are a combination of a physician professional component and a technical component. According to the CPT, when the physician component is reported separately, identify this service by adding modifier “-26.”

• -TC for Technical Component. When the equipment or technician performs the test, add the modifier “-TC” to the procedure code identified for the technical component charge. Remember, the technical component represents both the equipment and the staff person performing the test. Trying to bill for staff time in addition to the test itself is improper and would raise a red flag.

Other contemporary issues surrounding these tests are being subject to the rule first established in 2013 called the Multiple Procedure Payment Reduction (MPPR). This means that if you perform multiple special ophthalmic procedures on the same day, full payment is made for the -TC service with the highest payment under the Medicare Physician Fee Schedule. Payment is made at 75% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice) to the same patient on the same day.

As you can see in the example below (See “More on Modifiers”), the CPT code 92025 would be paid in full because it is the highest-paying procedure, and the technical component of 92285 would be paid at 75% (reduced by 25%). According to CMS’s MLN Matters, this rule applies to all ophthalmic special procedure tests, as well as most ophthalmic ultrasonography tests. For more information, visit bit.ly/MLNMatters. OM

JOHN RUMPAKIS, O.D., M.B.A., is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.