coding & reimbursement
What's New in 2006?
What doctors can expect with coding changes for this year.

There are a number of changes to the Medicare program in 2006. The one that has received the most publicity is the new Medicare Part D drug benefit, but there are other changes that impact ophthalmic practices.

Some codes (Table 1) are changing. Most of these changes are not mainstream codes in most practices, but have application in some offices. There are new Category III CPT codes of interest (Table 2). Category III codes do not have fee schedule amounts, and may not even be covered. However, when a category III code exists, it should be used in preference to a miscellaneous code. There are new HCPCS codes and modifiers (Table 3).

Glaucoma Screening Benefit

The benefit has been expanded. In addition to Medicare beneficiaries with a family history of glaucoma, those who have diabetes, and those who are African-American and over the age of 50, the benefit now expands to include Hispanics age 65 and older. Bill these visits with procedure code G0117 (glaucoma screening for high-risk patients furnished by a physician) and diagnosis code V80.1 (special screening for glaucoma).

The visit requires documentation in the medical chart of a dilated exam, an IOP measurement, and direct or slit lamp ophthalmoscopy. It is bundled with concurrent ophthalmic services.

Since the inception of this benefit in 2002, the utilization has been very low. In 2003, only 1,840 claims were paid by Medicare. Even though reimbursement is low (2006 proposed MPFS is only $42.69), it is a way to reach out to the community and increase your patient base.

UPINs

UPINs are unique provider identification numbers, used when ordering or referring for certain services (e.g., tests, consultations). Effective for claims processed on or after April 1, 2006, Medicare will no longer accept the surrogate UPIN, OTH000. Claims that require a doctor's name and UPIN must have a valid UPIN number.

The surrogate UPIN was intended for use by new doctors during their application process for a new provider number. It has morphed into a catch-all when practices don't want to be bothered to look up a valid UPIN. You can look up doctors' UPINs on line at http://upin.ecare.com/.

Of course, once the National Provider Identification (NPI) goes into effect in 2007, UPINs will likely not be needed.

Conclusion

CPT and HCPCS codes and modifiers are constantly being changed and updated as medical care evolves. These changes are implemented annually, but changes can also occur on a quarterly basis. Monitor your carrier bulletins and notices to keep on top of the latest information.

Suzanne Corcoran is vice president of the Corcoran Consulting Group. She can be reached at scorcoran@corcoranccg.com.