Filing claims for glaucoma care

Article Outline

 

The American Optometric Association Third Party Center offers some hints on how to properly file claims on the care for patients with glaucoma.

Office visits may be coded either as intermediate or comprehensive ophthalmologic services (Current Procedural Terminology [CPT] codes 92002 or 92004 for new patients and 92012 or 92014 for established patients) or as evaluation and management (E&M) services (99201-99205 for new patients or 99211-99215 for established patients).

In every case, the visit code is chosen by comparing the content of the patient's medical record for the day with the definitions for services provided in the CPT codes.


•In the case of the intermediate and comprehensive ophthalmologic services, the definitions are fairly subjective while still including several requirements. In no case should a code be chosen casually. (Never simply say, “we always use 920XX for this type of visit.”)


•For evaluation and management services, the CPT definitions are more specific and objective. A code is chosen by comparing the contents of the case history, the physical examination, and the medical decision-making to the requirements of the definitions. The choice is made even more specific by applying the Documentation Guidelines for the Evaluation and Management Services, created jointly by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) in 1997.


•AOA members have access to resources for helping in the choice of codes, including:

•AOA Codes for Optometry—This 2-volume set, updated annually, includes Current Procedural Terminology codes applicable to optometry, ICD-9 codes pertinent to eye care, HCPCS codes for materials covered under Medicare, the E&M Documentation Guidelines for the Evaluation and Management Services, the U.S. Centers for Medicare & Medicaid Services (CMS) Correct Coding Initiative tables, and more. It is available through the AOA Order Department.


•AOAReimbursementPlus.com—A Web-based subscription service providing a compendium of information regarding codes, fee schedules, and other valuable information to assist offices in dealing with medical records and insurance issues.


•AOACodingToday.com—Another Web-based subscription service providing an easy way to look up ICD, CPT, HCPCS codes; national and regional guidelines for combinations of codes; and national and local coverage determinations for Medicare.





Visit the AOA Web site (www.aoa.org) or go directly to http://AOA.ReimbursementPlus.com or http://aoa.codingtoday.com/ for more details about these programs.

These same resources can help practitioners choose the procedure codes to represent the testing performed during visits for the diagnosis and management of glaucoma. These visits often include one or more special ophthalmologic services such as visual fields (92081-92083), retinal photos (92250), retinal imaging (92135), gonioscopy (92020), and others. Payers often restrict which combinations of codes they will pay for, so it is important to visit each payer's Web site to learn if there are such restrictions on the services provided to patients. Medicare uses Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) to provide such guidance, all of which are available on the Web sites of the regional Medicare carriers and the CMS.

Electronic health records (EHR) are integral to most of the current computer-based office management systems. These systems can also be extremely helpful in collecting data as the practitioner proceeds through an office visit. They are also helpful in choosing the suitable codes for appropriately reporting the visit and the procedures completed during the visit—both to the patient and to the patient's insurer.

Be sure to check the AOA's Web site frequently for assistance in choosing codes accurately, as well as for the information on in-office protocols for the provision of care for glaucoma and many other conditions. The AOA Clinical Practice Guidelines are available for download on the AOA Web site, including those for glaucoma (www.aoa.org/documents/CPG-5.pdf). When in doubt, practitioners may also access personal assistance by using a special AOA member special service, Ask the AOA, at www.aoa.org/x8587.xml.