Optimizing Glaucoma Reimbursement
Obtaining full payment for office-based services.
BY RIVA LEE ASBELL

A large part of revenue generated by glaucoma specialists comes from the office practice and associated diagnostic testing. This article presents ways for the glaucoma specialist to optimize reimbursement while maintaining compliance. The rules expressed come directly from Medicare.

Consultation Codes: Some Tips

Consultation codes reimburse significantly higher than a comparable office visit code at the same level in E&M (Evaluation and Management) coding. For example, a level 4 consultation code in 2005 has a national average (non-facility) of $172.81 vs. a level 4 new patient office visit reimbursement of $137.18. Most initial encounters by a glaucoma specialist are consultations; however, there are strict rules for coding and billing consultations that must be followed.

This is a Medicare example of a consultation:

"A general ophthalmologist diagnoses a patient with a retinal detachment. He sends the patient to a retinal subspecialist to evaluate the patient because the general ophthalmologist does not treat this specific problem. The retinal specialist evaluates the patient and subsequently schedules surgery. He sends a report to the referring physician explaining his findings and the treatment option selected."

Substitute "glaucoma subspecialist" for "retinal subspecialist" and you see that most initial encounters can be coded as consultations.

Here are some tips to help you:

► Another physician or appropriate source must be requesting your opinion or advice — without this it is not a consultation

► The request must be documented in the patient's medical record and this is best done in the chief complaint. It does not have to be a written request from another physician. Yes, the request must be documented; however, the request itself may be verbal and transmitted by the patient.

► A written report must be provided to the referring physician, even if this is a physician in the same group practice. Consultations among members of the same group are definitely permitted by Medicare. If you are in an academic medical center be careful, because many compliance people have not read the regulations and are not aware of this.

► For intraoffice consultations the shared medical record allegedly suffices; however it is better to write a short note to protect yourself under audit. I have had various conversations with different carrier medical directors and have received varying responses.

► Payment may be made regardless of treatment initiation, be it surgery or medical. This has been a misunderstood concept for many years.

► Subsequent visits are to be reported as established patient visits.

Prolonged Services

There is a category of codes known as Prolonged Services that are usually not used in ophthalmology, but that have great use in the glaucoma practice. These codes can be used for those patients who remain in the office for a prolonged period and need intensive care such as when a patient with acute glaucoma presents.

CPT (Current Procedural Terminology) states that these codes are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to other physician services, including evaluation and management services at any level. An appropriate code should be selected for procedures performed in the care of the patient during this period.

Following are the appropriate codes:

► +99354: Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (list separately in addition to code for office or other outpatient Evaluation and Management service)

► +99355: each additional 30 minutes

Here is the table to make the calculations:

Total Duration of Prolonged Services Code(s)

[First 30 minutes not reported]

30-74 minutes   99354 x 1

75-104 minutes   99354 x 1 + 99355 x 1

105-134 minutes   99354 x 1 + 99355 x 2

135-164 minutes   99354 x 1 + 99355 x 3

165-194 minutes   99354 x 1 + 99355 x 4

Here are some tips to help you:

► Time counted must be face-to-face time with the physician and not auxiliary personnel.

► Time counted is for the total duration of face-to-face time that the physician spends with the patient, even if the time is not continuous.

► The codes reported must be the time equivalent of the E&M code plus an additional 30 minutes before you begin your calculations. Each code typical time allotment is noted in its CPT description. For example the typical time for a level 4 consultation is 60 minutes.

► Separate consultation codes exist for inpatient and outpatient services.

► Do not use for counseling or coordination of care.

► The national average (non-facility) for the outpatient codes for 2005 are:

+99354 — $99.29

+99355 — $98.15

► CPT uses the + symbol before a code to designate the code as an add-on code. Add-on codes do not take modifier -51 and pay at 100% of the allowable for that code.

► Be sure to document your face-to-face time precisely.

Here is an example to help you:

Patient is seen for evaluation of painful red eye after being examined by an outside physician. Patient has acute glaucoma and spends the day. Documented physician face-to-face time is 3 hours and 15 minutes.

Total duration of prolonged services is 105 minutes (Consult = 60 minutes CPT typical time plus 30 mandatory waiting minutes)

The Math: 195 minutes (face-to-face time) minus 90 minutes (from the consult plus 30 minutes mandated non- billable time) = 105 minutes.

Code and bill:

99244 Level 4 consult ($172.81)

+99354 x 1 and +99355 x 2 ($99.29 + $98.15 x 2 = $295.59)

On a national average, we have accumulated $468.40. This encounter, if properly documented, may qualify for a level 5, but I usually avoid level 5 consultation codes since they are a guaranteed invitation for an audit. Level 5 new patient visits do not present the same problem.

Follow-up Office Visits

The glaucoma specialist has to follow patients with great frequency and there is always a lively discussion on which are the best codes to use and which are the permitted codes to use. The big discussion usually centers on whether to use CPT code 92012 or 99213 (Eye code vs. E&M code).

The intermediate follow-up eye code has one examination requirement, namely external and ocular and adnexal examination where E&M code 99213 specifies only that at least six elements be performed. The description of the code states it may be used for continuation of a diagnostic and treatment program. The difference in reimbursement (national average non-facility) in 2005 is $12.50. Be careful, however, because those of you doing only an IOP check and a vision exam can only be a low level E&M 99212.

Diagnostic Testing

Many of the special ophthalmologic diagnostic tests listed in CPT are used daily in a glaucoma practice. You need to capture these along with the office visit coding and while they can be billed on the same day, you need to review your carrier's LCDs (Local Coverage Determinations) to make sure you are in compliance.

Here are some tips to help you:

► Serial tonometry (CPT code 92100). Many of us (including me) tend to think of serial tonometry as a test for diurnal fluctuations in IOP. Not so, for CPT. When treating an attack of acute glaucoma you can bill for serial tonometry if you check the IOP more than three times in the same session. Empire Medicare now has a draft policy that states the readings must occur over a 6-hour period.

► Gonioscopy (CPT code 92020). Gonioscopy has been unbundled from office visits since July 1, 1999. Don't forget to bill for it.

► Pachymetry (CPT code 76514). Be sure to read your carrier's LCD for when you can bill it. It is a bilateral test so the fee includes examination of both sides.

► Rules. You must abide by your carrier's LCD on such issues as frequency, chart documentation requirements and acceptable CPT and ICD-9 codes. Also, be sure to keep up to date with the edits in the National Correct Coding Initiative.

► Orders. Though you are a glaucoma specialist and want to have certain tests, such as visual fields, available before you do your initial evaluation, it is not acceptable to have any diagnostic testing performed until after you have initially and personally examined the patient and written an order in the chart.

Perils and Pitfalls in Chart Documentation

Here are some tips to help you:

► Comprehensive eye codes (CPT codes 92004 and 92014) require confrontation fields as a mandatory element. If the patient is being followed with automated perimetry, be sure to note that in the area designated for confrontation fields

► Nearly all the diagnostic tests require an interpretation and report. It is a report that addresses clinical findings, comparative data and clinical management. For further information, visit my web site (www.RivaLeeAsbell.com) and read the article entitled "The Three C's."

► Consultation codes are E&M codes and if you are going to use them you must follow the E&M guidelines with no exceptions. I personally advise against using level 5 consult codes, not because you don't have that level on certain patients, but simply because it is an invitation to audit.

► Be sure to use a forced entry examination form (one with check boxes) and document negatives as well as positives. Mark boxes individually. Do not use squiggly lines, an auditor may interpret that as passing through the elements and not performing them.

► If you use a separate history form, be sure it contains all the organ systems that need to be reviewed for a comprehensive E&M history and not just disease entities. When using a separate form, the physician must sign off on the form and review it with the patient or it does not count.

Check Your Coding Acumen

Here is a little homework assignment. Take a look at your last acute glaucoma patient's billing. Did you leave anything behind? Was your chart in compliance? Good luck!

CPT codes copyright 2004 American Medical Association

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com