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.

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