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  CODING STRATEGY

PREVENT PITFALLS

KNOW COMMON MISTAKES TO AVOID WHEN OFFERING WELLNESS

JOHN RUMPAKIS, O.D., M.B.A.

WELLNESS AND prevention are big topics in health care today. As such, O.D.s are looking for ways to incorporate these concepts into their practices – more on that later.

From a medical coding and reimbursement perspective, most wellness and preventive measures in eye care currently are not covered by third party carriers and are paid for out of pocket by the patient. These services and subsequent payments are not applied to the patient’s ever-rising deductible either – so these services are truly out of pocket for the patient.

Is that a bad thing? It depends on perspective. I know many O.D.s who would prefer to keep these types of services outside of third party coverage to maintain control of delivery and pricing. I know others who want to provide only services covered by a third party so they don’t have to discuss non-covered items, out-of-pocket payment, etc., with patients.

Rather than slant perspective by sharing my personal opinion, I will identify pitfalls when billing for preventive care services.

CPT CODING

It is important to know the CPT requires you to use the existing CPT code that most closely represents the service you are providing. This means you cannot create your own code, use an “internal code,” or use a code that circumvents coverage by a third party payer.

For example, it would be acceptable to create an ocular surface wellness package for those patients who do not have dry eye signs or symptoms and provide counseling and nutritional support to prevent dry eye.

However, be cautious in creating a “dry eye” bundled package for individuals who do have dry eye; these individuals now have a valid chief complaint and the services provided are covered services, but now bundled into a package. These services, when properly provided and described, are covered office visits described by the CPT and could be challenged by a patient or carrier if offered in a wellness package.

SPECIAL OPHTHALMIC PROCEDURES

Many devices today have multiple settings on the same device, including a screening setting that can be used in a wellness package.

For example, I could create a retinal wellness package that consists of a screening OCT and a screening retinal image and bundle the two together. There are critical items that must be in place before I could do this. The necessary devices must have screening settings and there cannot be any known retinal disease present.

The code I would use is “S9986 – Not Medically Necessary Service,” thus defining the elective and preventive nature of these tests.

It is important to understand, if your devices do not provide differential testing or imaging, this most likely is not an option as you cannot call the same OCT test or describe the same retinal image in two different ways, and code it two different ways. That would be inappropriate.

STICK WITH THE CODE

Wellness and prevention are making significant progress within the health care industry and mainstream carriers — even Medicare — are beginning to embrace these concepts. They can be an effective strategy you employ to offer healthy patients additional services to prevent or to detect common ocular maladies.

Whether or not you make this offering, please make sure you are proactive and apply the rules of coding and compliance to your practice. OM

DR. RUMPAKIS 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.