Recent Answers to Claim Billing Questions

Dr BrownlowCharles B. Brownlow, OD, a national consultant for optometry on issues related to third party, recently provided these answers to questions from OOA members.

Question: If we see a patient with early stage cataracts and recommend a 12-month recall for their annual exam to monitor the cataract progression, would that exam at the 12-month time only be a short, specific visit to evaluate for cataract changes? If the RFV was to monitor for cataract changes, at what point do we look at other aspects of the eye health (glaucoma eval, retinal eval, etc.)?

A. The RFV (and the order in the previous record to RTC for re-evaluation of a medical condition) support sending the claim to the medical insurer. Your professional judgment determines what questions are asked and what tests are done during the visit, which then determines what code is used to report the visit and any other services you provide during the encounter.

Q. If a patient, age 71, has no ocular diagnosis (e.g., cataract, glaucoma suspect, dry eyes) but they call to come in for an eye exam, would this fall under “routine” and not be covered under medical?

A. If there is no medical reason for a visit, the visit is billed to the patient and/or the patient’s vision plan. Medicare rules are very clear; they do not intend to pay for services without a medical reason or for screening for medical conditions, even if one or more medical diagnoses are made during the visit. Subsequent testing, even on the day of the visit, will be covered if driven by a diagnosis or suspected condition is identified during the visit, but payment for the visit itself will be the responsibility of the patient.

Q. If the patient’s GP recommended an eye exam because it had been two years, even though no medical diagnosis was present, or if the insurance company urged the visit, how do we code?

A. If the visit is recommended by another “covered entity” (provider or insurer) for a medical condition or suspicion of a medical condition, that is the reason for visit. An example notation might be: “Patient in the office at Dr. ____’s order for examination of ____.”

Q. A patient with diabetes but no pre-diagnosed retinopathy calls for an eye exam because his GP recommended it and we do a complete exam. The insurance has comprehensive eye exams covered under “preventive” benefits without any copay. However, if there is a medical diagnosis, such as diabetic history, it would fall under a medical visit with a $40 copay (for instance). How would this be submitted? The patient states that they’re entitled to an eye exam without copay.

A. Technically, if the reason for visit is medical, the claim should go to the medical insurer. However, if the patient has a vision plan, they deserve to get that benefit sometime during the benefit period. Each office has to develop a firm policy of how to handle this. If it is an acute medical problem, it’s easy. The care must focus upon the acute problem and the care is billed to the medical insurer. If it’s a chronic medical issue (e.g. diabetes without retinopathy), then it is more of a challenge. If your judgment is that this visit is largely focused on the medical issue, you need to firmly explain to the patient the limitations of vision and medical insurance and bill the medical. If this visit is largely focused on the refractive side, though the patient has a medical problem you are managing, you bill the vision plan. 

Q. If a patient refuses to be seen during a post-op period for a YAG or cataract surgery, do we still bill for the post-op period? I am getting conflicting answers from the surgeon’s staff and my doctor.

A. The claim cannot be submitted until you have seen the patient once during the 90-day post-op period. In other words, if the patient does not come to your office during the 90-day period, you cannot bill for the post-op care.

Q. “This service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD).  The member is not responsible for this charge.” We were denied when we billed 92083 Visual Field for a patient who is glaucoma suspect (365.00) and when we billed for another patient 92250 Fundus Photography (Optomap) for a diabetic patient (250.02).I’ve appealed the denials by explanation as to why these test were essential in diagnosing and treating our patients. Both appeals were denied. I’m confused because these services are standard of care. In the future, how will I know that services and or tests don’t meet the requirements by the LCD and NCD?

A. Most insurers no longer pay for fundus photos for patients with systemic diabetes until the photos are used to document diabetic complications in the patient’s eyes. The zero after the decimal point in the code you used (250.02) indicates there are no complications, thus telling the insurer that these photos are screening for medical conditions and not covered. Screening photos are important and the patient should pay for them if and when the insurer does not.

As for the glaucoma suspect, you may be paid if you use a different Dx code, such as 365.01, “open angle, with borderline findings,” rather than 365.00, “Preglaucoma, unspecified.”  Most insurers don’t like codes whose definitions include ‘unspecified.’

Q. A doctor received notice to reapply for DME in May 2013. He did not respond. Now he will reapply in 2014. Will payment go for three years starting in 2014 or will payment be applied to 2013 and two more years?

A. The registration is for three years from when the application is received by DMERC. In a sense, the doctor is starting over fresh, not extending an existing registration.

Q. Please explain the difference between codes 68810, 68811 and 68815.

A. 68810 is defined by CPT as “Probing of nasolacrimal duct, with or without irrigation.”  68811 is “Probing of nasolacrimal duct, with or without irrigation, requiring general anesthesia,” and 68815 is “Probing of nasolacrimal duct, with or without irrigation, with insertion of tube or stent.”

Q. How far back can your records be audited by Medicare or other insurance companies from the current date?  I know you have to keep your patient records for seven years before they can be destroyed.

A. Medicare can go all the way back to the first claim you submitted. There is no statute of limitations for them. That’s impractical of course, so most audits are done on a few records (maybe 20) with the results extrapolated back to three years. Some of the carriers will go back five years if they suspect inappropriate ‘auto-population’ in electronic records. The length of time charts must be kept is separate from audit rules and subject to state law. Seven years is the most common number.

AOA Provides ICD-10 Resources

The AOA has provided a list of resources for ICD-10 available to members. You can read the summary here: AOA ICD10 Resource Summary.

The summary reflects what is available today – resources are continuously being updated.

The Medical Records and Coding Service for AOA members is provided by the Third Party Center (TPC) Coding Experts, Doug Morrow, O.D., Rebecca Wartman, O.D., and Harvey Richman, O.D. All medical records and coding questions can be sent to the email address: or questions may be submitted online at

For questions pertaining to “Ask the Coding Experts” webinars, please email

March is “Save Your Vision” Month

Save-Your-Vision-logo-1024x910Optometrists can make a difference and change people’s lives by participating in Save Your Vision Month, sponsored by the American Optometric Association during the month of March.

Ohio optometrists can participate in several ways, such as donating a percentage or a day of eye exam fees, or donating $2-$5 per frame sold during March. Another way to support Save Your Vision Month is through a donation to the Ohio Optometric Foundation. Mail your check to: PO Box 6036, Worthington, OH 43085.

Additionally, donations can be made to Optometry Cares, the AOA Foundation, in support of Save Your Vision Month 2014. Mail to: Attn: Optometry Cares, SYVM, 243 N. Lindbergh Blvd., Floor 1, St. Louis, MO  63141.

Finally, optometrists can purchase a Save Your Vision Month Kit for $25 from AOA. The kit includes 25 wristbands, posters, stickers, balloons and other promotional material for your office. You can request an order form via email:

Some Good News for Our Members and All Providers

Dr Jay HenryBy Dr. Jay Henry – CMS is extending the deadline for Eligible Professionals (EPs) to attest to Meaningful Use (MU) for the Medicare EHR Incentive Program 2013 reporting year from 11:59 p.m. ET on February 28, 2014, to 11:59 p.m. ET March 31, 2014. This extension does not impact the deadlines for the Medicaid Electronic Health Record (EHR) Incentive Program.

Additionally, 2014 is a special reporting year. All EPs regardless of stage will be required to meet and report on MU for a quarter for 2014. It is locked to a calendar quarter for Medicare but not for Medicaid.

CMS announced its intent to change the Meaningful Use Stage 3 timeline, as well as extend Stage 2 through 2016. However, please note:

  • This does not delay the start of Stage 2 Meaningful Use that began Jan. 1, 2014.
  • This does not affect the current reporting periods and deadlines for 2014 participation.

What This Means for Providers

If you begin with your first year of Stage 1 for the Medicare EHR Incentive Program in 2014:

  • You must begin your 90 days of Meaningful Use Stage 1 no later than July 1, 2014, and submit attestation by Oct. 1, 2014, to avoid the 2015 payment adjustment. Consequently, providers who start their 90-day Stage 1 reporting in 2014 will have to attest before October 2014 to avoid 2015 and 2016 penalties.
  • 2014 is the last year a Medicare provider can start the program.

If you have completed Year 1 of Stage 1 Meaningful Use:

  • You will demonstrate a second year of Stage 1 Meaningful Use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
  • You will demonstrate Stage 2 Meaningful Use for two years – 2015 and 2016.
  • You will begin Stage 3 Meaningful Use in 2017.

If you have completed two or more years of Stage 1 Meaningful Use:

  • You will still demonstrate Stage 2 Meaningful Use in 2014 for a three-month reporting period fixed to the quarter for Medicare or any 90 days for Medicaid.
  • You will demonstrate Stage 2 Meaningful Use for three years – 2014, 2015, and 2016.
  • You will begin Stage 3 Meaningful Use in 2017.

Some Statistics

  • More than 93 percent of all eligible hospitals have registered to participate in the EHR Incentive Programs.
  • Approximately 82 percent of all EPs have registered to participate in the EHR Incentive Programs.
  • More than 61 percent of all Medicare EPs who have received an EHR incentive payment are non-primary care.

PQRS has changed for 2014

Most PQRS reporting options require an EP or group practice to report nine or more measures covering at least three National Quality Strategy (NQS) domains for incentive purposes.

The domains associated with the measures are as follows:

  • Patient Safety
  • Person and Caregiver-Centered Experience and Outcomes
  • Communication and Care Coordination
  • Effective Clinical Care
  • Community/Population Health
  • Efficiency and Cost Reduction

To be a successful PQRS provider during 2014 and receive the incentive payment, you must submit nine PQRS measures half the time that they apply based on diagnosis code and procedure code.  You can avoid the 2016 payment penalty (but you will not get an incentive payment nor be considered successful in terms of PQRS) by successfully submitting at least three measures 50 percent of the time that they apply.

Visit the PQRS link at for up-to-date information and the PQRS codes that apply for ICD-9 and ICD-10 diagnosis for 2014.

New Rules Regarding Termination of Doctor-Patient Relationships and Proper Notice to Patients upon Physician Termination

By Daniel Zinsmaster, Esq. – Ohio law has undergone a number of developments concerning the appropriate means of notifying patients when a physician leaves a practice, as well as the proper steps for terminating a patient from a medical practice. Effective March 22, 2013, health care entities were required to advise patients when an employed physician left the entity or medical practice, regardless of whether the physician’s departure was a result of the employer’s or the practitioner’s decision (Ohio Revised Code Section 4731.228). Now, administrative rules recently amended or adopted by the State Medical Board of Ohio (“Board”) attempt to provide further clarity to this requirement, as well as outline the necessary steps for discharging or terminating an individual patient from a medical practice.

Effective December 31, 2013, any physician leaving, selling or retiring from a practice must comply with Ohio Administrative Code Rule 4731-27-03. Within 30 days of learning of a physician’s termination or resignation, a medical practice must send notice by mail or by HIPAA-compliant electronic means to all patients treated by the departing physician within the past two years. A medical practice may transfer this notification mandate to the departing physician by providing a list of patients treated along with patient contact information to the physician.

The notice to patients must contain all of the following:

  • A statement that the physician will no longer be practicing at the health care entity,
  • The date the physician ceased or will cease providing services at the health care entity,
  • If the physician will be practicing at another location, the contact information for the physician’s new location,
  • Contact information for alternative physicians at the health care entity who can provide care to the patient, and
  • Contact information so the patient may acquire their medical records.

 The notification requirements do not apply to physicians who have provided treatment on an episodic basis, in an emergency department setting, or at an urgent care center. Notice is not required to patients treated by medical residents, interns and fellows. Furthermore, a health care entity is not required to provide contact information for the physician’s subsequent location when a good faith concern exists regarding patient safety.

In terms of the discharge or termination of a patient from a medical practice, the physician must send notice by certified mail, return receipt request, or by HIPAA-complaint electronic means to the patient. If the electronic communication is not viewed within ten days by the patient, notice by certified mail must be provided. The notice must state that the physician-patient relationship has been terminated, that the physician will provide emergency care and access to services for up to 30 days, and that the patient’s medical records will be available to transfer to another provider. The physician is not obligated to aid or assist the patient in acquisition of a new provider.

Similar to an individual physician’s departure from a health care entity, a physician is not required nor expected to provide notice of formal termination if the physician treated the patient in an emergency setting or on an episodic basis. Moreover, notice of termination is not necessary if the patient’s care has been formally transferred to another physician who is not within the same medical practice, or when the patient is the person responsible for terminating the physician-patient relationship. Nonetheless, such events should be documented in the patient’s chart.

Ohio physicians must also be cognizant that ethical mandates published by the American Medical Association and the American Osteopathic Association similarly prohibit patient abandonment, and set forth appropriate steps for ending physician-patient relationships. Breach of statute, administrative rule or ethical code may expose a physician to professional licensure sanction by the Board and other entities. In light of this evolving area of health care regulation, medical practices and individual physicians must be mindful of the specific notification mandates when an established physician-patient relationship is concluded.

Daniel Zinsmaster is an associate with the Columbus office of Dinsmore & Shohl, LLP.

Protect Your Hands from Injury

Article provided by Paul Feck, Frank Gates Company, and the Ohio Bureau of Workers’ Compensation Division of Safety & Hygiene – We use our hands for so many things that we often take them for granted. Because of this, they are the most frequently injured part of the body. Planning ahead, paying more attention to your hands, keeping them out of harm’s way and using appropriate personal protective equipment can help prevent most of these injuries.

Hospital emergency room studies confirm that hand and finger lacerations are one of the most common injuries treated. Skilled tradesmen account for about a third of those injuries. Malfunctioning machinery, uncommon work tasks, increased work pace and distractions contributed to injuries. Workers who wear gloves seem to suffer fewer hand injuries.

What are the major sources of hand injuries?

  • Trauma resulting from mechanical hazards, such as cuts, abrasions, punctures, broken bones and amputations.
  • Electricity and heat sources resulting in burns and possible nerve damage.
  • Chemicals and other irritants leading to chemical burns, abrasions, simple skin irritation and dermatitis.

Why do we incur hand injuries?

  • Inadequate machine guarding
  • Missing machine guarding
  • Using the wrong tools
  • Using tools incorrectly
  • Inadequate training for the task being performed
  • Not wearing appropriate hand protection
  • Inadequate personal hygiene
  • Using inappropriate solvents and cleaning agents
  • Not following proper ergonomic practices

What are ways to prevent hand injuries?

  • Keep machine guards in place
  • Properly use the correct tools
  • Remove hand jewelry
  • Use lockout / tagout procedures to prevent unexpected start-up of equipment
  • Keep tools in good condition
  • Keep your work area clean and free from debris
  • Obtain training on proper tool usage
  • Don’t use your hand as a temperature gauge
  • Use barrier creams to prevent skin contact with irritants

How do gloves protect the hands?

  • Cotton gloves can protect against abrasions, cuts, snags and temperature extremes.
  • Leather gloves protect against rough surfaces, heat, cuts and sparks.
  • Cut-resistant gloves can protect against sharp edges and thermal hazards.
  • Chemical-resistant gloves resist penetration and permeation; and can protect against dermatitis, chemical burns and corrosion.

Gloves can provide protection from a variety of concerns, but they must be used with care, and the proper selection for the hazard is critical. In some cases, gloves can contribute to injuries. Understanding the types of gloves, and their appropriate uses, is the key to a good hand-protection program.

Protecting your hands is a constant job. Whether it is un-jamming a machine, loading parts, changing tools, lifting a tray or any other job using your hands, think about the job before you do it and imagine what could happen. Assume it could happen, and take appropriate action to prevent an injury. Use your head to protect your hands.

The ACA and Practical Applications

By Dr. DavDr. David Andersonid Anderson –  So, the Affordable Care Act is here – now what? I know we have all seen some impact from the changes brought by the ACA. Some were with our own insurance plans and unexpected. Some were with insurance that our patients have. Some changes will be from new patients who previously didn’t have health coverage. With all of this change, a few questions came to mind.

  • Where do I go to evaluate the exchange plans to find out whether I am a provider for these plans?
  • How do I find out the fee schedule for these new plans?
  • How do I know if I am a provider for the “new” plans that are subject to ACA minimum requirements to be a privately sold plan?
  • I understand there will be a new network with the potential for providers being left off plans (e.g. UHC and other skinny networks). How do I find out if I am included, or have been dropped from the network?
  • How do I find the fee schedules for these plans?
  • In my area, there are some newly developed Accountable Care Organizations (ACO’s) that are self-insured by a hospital group. How do I find out about these plans?
  • How do I know which medical plans cover children’s vision benefits, and which plans have subcontracted the services/materials to a vision plan?

The best place to find answers is with the specific carrier of these plans and their provider portal information. Health care providers should have been notified by mail of any changes at the end of last year. In most cases, if you are already a provider for Medical Mutual, Humana, Buckeye, CareSource, Molina or Paramount, then you are already a provider for those on the exchange as well, and the new ACA minimum-required plans.

Speak with your carrier representatives, and email them your questions. This gives you a permanent record. The reps can give you more specifics for their plans. Each company is free to provide these plans, within certain guidelines as laid out by the ACA, as they find most appropriate. The insurance companies will use existing fee schedules unless they have new signed agreements or amendments with you. In many cases, this means Medicaid levels of reimbursement. Additionally, each insurance company has a website that you can access for information. You can find out if you are a provider by searching for your own name on their “find a doctor” feature on each website.

The exchange plans sold in Ohio can be found on This website allows a search by county to find out about the new exchange plans and provider panels. Generally, you will have to request fee schedules by providing specific CPT codes. Admittedly, the website is set up for those people looking to purchase an insurance plan, but there is still information about the plans that our patients will be gaining access to.

Some information is not readily available at this time, such as how certain ACOs affect you and your patients. This is a new and rapidly changing area of health care. At this point, discussion with your patients and perhaps administrators at your local hospital group may be the best way to gather information about these plans.

When we review vision benefits, the ACA law requires each plan to provide a comprehensive examination and materials to children age 18 and under. Each insurance company has its own way of interpreting how this benefit is to be implemented. In some cases, the eye care product will be subcontracted to a vendor like VSP or EyeMed. In other cases, the plan will be managing the vision portion themselves. The websites are a good source for ACA-related product information. Continue watching this OOA Blog for further updates on this topic.

In summary, through all the confusion there is information available. Certainly, much more change will come. The best advice is to know the plans you are on, and contact those plans to ask about how they intend to comply with the children’s benefits.

Ask them if vision benefits will be subcontracted to another company. Ask them if there are new networks and if you are still on them. Decide which of these plans are most suited to your practice and your patients. Finally, be ready for a shift in both patient demand as well patient coverage for optical goods for some plans.

One final question: Is the ACA here to stay? Whether it is or not obviously will play out in the next year or two. We must work hard from all facets of healthcare reform to assure that primary eye care is a core component of every individual’s health care.

Value of Primary Eye Care

By RichazW8A1974Ard Cornett, OOA Executive Director – The conclusions in a study recently released by HCMS Group in cooperation with VSP Vision Care are a must-read for optometrists.

The study states: Optometrists can detect early signs of chronic disease before other health care providers. Eye doctors were the first to identify signs of diabetes in patients 34 percent of the time, high blood pressure 39 percent of the time, and high cholesterol 62 percent of the time.

People who get an annual comprehensive eye exam are more likely to enter the health care system earlier for treatment of serious health conditions, which significantly reduces the long-term costs of care.

You can read more about the study on the HCMS website.


Marketing the InfantSEE Program at the Local Level

Miller 968By Jason Miller, OD, MBA – InfantSEE®, the American Optometric Association’s public health program to provide comprehensive eye assessments to infants in the first year of life at no cost, has firmly taken root since its introduction in the summer of 2005. How can optometrists best promote this public health program in their communities?

Fortunately, it is not difficult. The InfantSEE® public awareness campaign was designed from the start to be applicable at both the national and local levels. Read my column, InfantSEE in Optometry that was first published in 2007. The information remains current today.

Dr. Miller is a member of the Ohio Optometric Association and is the coordinator of the Central Ohio Optometric Association’s InfantSEE® program. He can be contacted at

AOA Brain Injury Manual

By DMontecalvo 953r. Brenda Montecalvo, AOA Vision Rehabilitation Section – Incidents of brain injury and its devastating effects are garnering greater public awareness due to the large numbers of returning soldiers being treated plus the recent spotlight on concussions in the NFL and as a result of automobile accidents.

With this increased awareness of visual complications from brain injury, the AOA Vision Rehabilitation Section has produced a new “Brain Injury Electronic Resource Manual.” The manual is a comprehensive resource developed to aid the primary care optometrists in evaluating patients with brain injury. For the best results for patients, ODs need to be involved in the full continuum of care.

For a limited time, February 3 through April 1, the Manual will be available on the AOA Website.

The Manual is an evidence-based approach with clinical pearls and advanced evaluation techniques for working with patients with brain injury. Volume 1 of the Manual focuses on evaluation and assessment of common visual conditions associated with brain injury. These include binocular vision disorders, accommodative issues and eye movement disorders.

The Manual includes elements such as a glossary, lists of commonly used equipment and an overview of the numerous tests. Volume 2 is being developed.