Coding and Billing for Optometrists: Relative Value Units (RVUs)

Coding and Billing for Optometrists: Relative Value Units (RVUs) in VHA Part 4: CPT Coding- The Key to RVUs VA Optometry IT Subcommittee

Authors Ballinger, Rex OD- Baltimore, MD Cordes, Matthew OD- The Villages, FL Fuhr, Patti OD, PHD- Salisbury, NC Ihrig, Carolyn OD- Buffalo, NY Katzenberger, Ann OD- American Lake, WA Kawasaki, Brian OD- Las Vegas, NV Lazarou, Zoe OD- Baltimore, MD Ryan, Raymond OD- Eureka, CA Whitesell, Bethany- Fayetteville, AR Zimbalist, Richard OD- Columbia, MO

Background Optometry is now included in the Relative Value Unit (RVU) based VA productivity methodology: – DSS (Decision Support System) RVU (do not confuse with clinical decision support systems) – CMS RVU (Relative Value Unit) system (VA specific) These systems are a costs accounting and clinical activity relational database system. All patient services will need to be correctly and accurately documented to ensure proper resource allocation and utilization. Resources include labor, equipment, support and other expenses.

VA Relative Value Unit (RVUs) Quick Review There are two different types of RVUs used in VA 1. DSS RVUs used for budgeting, cost accounting, and workload all of which are time related -This is directly related to stop codes, clinic appointment times assigned at the DSS level. set up, and RVU 2. CMS RVUs which are used to capture workload times as well as exam complexity coding -This is related to CPT codes!! -This is the RVU measure in the Office of Productivity, Efficiency and Staffing (OPES).

Background All optometrists who have outpatient and inpatient PCE (Patient Care Encounter) encounter workload with CPT coding is used in calculating physician productivity within VA. However, this applies to paid clinicians only. Productivity is expressed in Relative Value Units (RVUs) per physician provider FTEE that is dedicated to clinical duties.

VA wRVU Data Sources and Methods Physicians, chiropractors, optometrists, podiatrists, and psychologists who are transmitting outpatient and inpatient PCE (Patient Care Encounter) encounter workload with CPT coding which is used in calculating physician productivity (wRVUs). The database contains workload for VA PAID physicians, In-House FEE physicians, residents not assigned to providers on encounter forms, without compensation physician providers (WOCs) and contract physician providers (DSS-RVUs).

Understand YOU CAN’T BILL FOR WHAT YOU DO YOU CAN ONLY BILL FOR WHAT IS DOCUMENTED YOU CAN’T GET PROPER CREDIT FOR YOUR WORKLOAD UNLESS YOU CODE CORRECTLY and are MAPPED correctly YOUR CODING MUST BE TIMELY!! – Your DSS workload is captured monthly- your encounters must be in by the monthly deadline or your work is NOT captured and never will be!!!

CPT Codes This is the key to developing the correct RVU data. Be sure you carefully document all your CPT codes. We will cover all of the pertinent CPT code information for you in this CPT training module.

For wRVUs Current Procedural Terminology (CPT) codes are critically important!!! For all of Eye Care these codes are now constructed using Systemized Nomenclature of Medicine Clinical Terms (SNOMED-CT) terminology for all procedures. SNOMED structures are rigid and are not deviated from (don’t bother to try to create or invent your own).

Workload Derived from Encounters (DSS RVUs), CPT (wRVUs), Unique Patients NOTE: CPT codes are converted to practice level work wRVUs using the annual CMS and Ingenix files. All encounter CPT coding from workload described above is merged with the annual Medicare RVU files obtained from CMS and Medicare gap code RVUs obtained from Ingenix.

Physician Productivity Data The Physician Productivity Benchmarking Reports are designed to provide a management tool for the systematic, longitudinal measurement and reporting of clinical productivity, efficiency and staffing in VHA. The productivity benchmarking tool shows the average, range, and variation in productivity across specialties at the National, VISN, complexity group, and administrative parent level. This information can be used to identify areas of need or improvement within relevant comparison groups. Hence, its accuracy is critical!

CPT codes count towards workload

How All of this Information is Used

Quick Review By now your clinics should be set up properly: – DSS coding in place and capturing patient exam data (refer to Module 2 in this series). – Telephone contact set up (DSS 428/408 ) and data entered in a separate clinic note. – Visits for other services documented (such as DSS 408/449) and captured appropriately as outlined in Module 2, AND – All encounters need to be completed by end of the month to avoid working w/o credit given. Select CPT codes for ALL procedures performed!

CPT (Procedure) Code Categories 92000: Ophthalmologic Codes 99000: Evaluation and Management Codes 60000: Surgical Codes 70000: Radiological Codes 80000: Laboratory Codes Details of what codes should be used is outlined in the following slides

First and Foremost All coding must be supported by what is documented in the medical record.

92 vs 99 Series Codes for Eye Care Both E/M series codes are used for medical billing: 92 Codes- only for Eye Care These codes are predominantly used in Eye Care, but not exclusively 99 Codes- all Medical Care (including Eye Care) General Rule: the higher the ending number, the greater the E/M encounter complexity

Which E/M Codes to Use 92 Series or 99 Series? Depending on the patient population, it may be common to have 30-40 percent of visits coded with E/M codes in the 99201–99499 range. Frequently, referrals are coded with the 99201–99215 series.

E/M Code 99 Series An E/M code (99 series) may be used when a patient is seen for a medical reason that does not require any eye examination procedures. The most common instances when the E/M code 99 series is used are: – Limited exams that do not meet the exam elements of an intermediate eye exam, but do meet the elements of a low-level E/M code (e.g., follow-up contact lens visit). – High complexity or risk-prone exams that meet the documentation elements of a 99204/14 or 99215 E/M encounter. – Examinations for medical reasons when no eye procedures are performed (e.g., an acute care visit for subconjunctival hemorrhage).

Eye Exam CPT Codes CPT codes 92002, 92004, 92012, and 92014 are used for: – New and/or established ophthalmology or optometry patients that include the evaluation and management of a patient. – These codes are appropriate when the level of service includes several routine optometric or ophthalmologic examination techniques that are integrated with and cannot be separated from the diagnostic evaluation.

CMS Definition of “New Patient” Per CMS: the phrase "new patient" means a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. See CMS Frequently Asked Questions at: https:// questions.cms.gov/faq.php?id 5005&faqId 1969

92 Series Eye Codes – New Patient 92002 Ophthalmological Services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient. 92004 Ophthalmological Services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits

92 Series Eye Codes – Established Patient 92012 Ophthalmological Services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient. 92014 Ophthalmological Services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits.

99 Series Intermediate Exam History General medical observation External ocular and adnexal examination Other diagnostic procedures as indicated; May include the use of mydriasis for ophthalmoscopy.

99 Series Comprehensive Exam History General medical observation External and ophthalmoscopic examination Gross visual fields (CVF) Basic sensorimotor examination (EOM, PUPILS) Slit Lamp Biomicroscopy Examination with cycloplegia or mydriasis and tonometry. – **most payers require dilation to bill a comprehensive exam** It always includes initiation of diagnostic and treatment programs.

99 Series Comprehensive Exam The comprehensive services need not be performed at one session. Example: patient defers dilation at 1st visit, can not bill for dilation at subsequent visit if you already billed for a comprehensive exam on initial visit (this patient care deferral option is not recommended). Better to bill intermediate exam for both visits

Eye CPT Codes Many encounters will use the 92002–92014 Eye Care services codes. Diagnosis and treatment CPT codes are 92015–92396 Surgical eye and ocular adnexa codes are 65091– 68899

Eye Exam CPT Codes Usually optometrists and ophthalmologists use the 92002–92499 codes. When a technician does a simple acuity or visual function, the procedure codes 99172 and 99173 are appropriate. Dispensing eyeglasses is a continuation of the visit when the eyeglasses were prescribed or ordered and is not coded separately.

No Specific History or Medical Decision-making Guidelines for These 99 Exam Codes There are 13 eye exam elements that must be documented to validate a coding level: Testing visual acuity Gross visual fields Eyelids and adnexa Ocular motility Iris Pupils Conjunctiva Cornea Anterior chamber Lens Intra-ocular pressure Retina Optic disc If three to eight of these elements are documented, an intermediate exam (99203 or 99213) should be coded. If nine or more of these elements are documented, a comprehensive exam (99204 or 99214) should be coded (understand that 99 series i.e. E/M codes can also be used for medical reasons)

92 Series Bundled Services Some procedures are bundled/included as part of the 92 series eye exam codes. The bundled procedures are: Amsler grid Brightness acuity test (BAT) Corneal sensation Exophthalmometry Glare test History Keratometry Laser interferometry Pachymetry Potential acuity meter (PAM) Schirmer test General medical observation Slit lamp tear film evaluation and transillumination DO NOT capture a separate CPT code for these procedures if done as part of the exam using a 92 series eye exam code. All other services, tests, or procedures performed can be added as additional CPT codes, e.g., contact lens fitting, photography, foreign body removal, and refraction.

QUICK GUIDE FOR BILLING EYE EXAMINATIONS WITH 99 SERIES CODES ** code 99211 does not require the presence of a physician

Common Procedures not Bundled Code Separately! 92015 Refraction 92020 Gonioscopy 92525 Corneal Topography 92060 Sensorimotor Exam 92070 Contact Bandage Lens 92283 Extended Color Vision 65205/65210 Removal of foreign body, conjunctiva 65220/65222 Removal of foreign body, cornea 65430 Scraping for culture

Corneal Pachymetry (Ultrasound Technique) NOTE: Corneal Pachymetry (76514) is separately reportable (ultrasound technique) if a thorough evaluation of the cornea is performed along with – interpretation and report – no technical or professional modifiers should be reported. Code 76514 is reported only once, since it is considered a bilateral service. Therefore, if corneal pachymetry is performed on both eyes, modifier 50 should not be used.

General CPT Coding Optometrists usually use the ophthalmology codes in the 92002–92396 range (e.g., diagnosis & treatment) As well as the HCPCS codes V2020–V2799, and various other HCPCS codes. The most commonly used codes by optometrists are 92002–92014 for eye exams and 92015 for refractions. Optometrists associated with a refractive surgery program who do postoperative assessments will also frequently use 99024, postoperative follow-up visit.

Refraction Code Any time a refraction is performed, it should be reported as an additional code, 92015: Refraction (can only use once, no multiple units).

Diabetic Retinal Exams Dilated Retinal Exams for Diabetics, S3000 Diabetic indicator, retinal eye exam, dilated, bilateral. Diabetic patient exam encounters with a dilated, bilateral retinal eye exam as part of the comprehensive exam should be coded with additional code S3000 for the diabetic indicator.

Visual Acuity Screening When doing an occupational health screening use 99172 or 99173 (screening codes). These codes should not be used with 92002, 92004, 92012, and 92014 (General Ophthalmological Services). In addition, 99172 cannot be used with any other E/M code, and 99173 cannot be used with any E/M service within the eye code series.

Spectacle Fitting Minimal documentation requirements for optometrist or eye technician for the use of codes 92340-92342 include: – measurements of anatomical facial characteristics, – records the laboratory specifications, and – performs the final adjustment of the spectacles to the visual axes and anatomical topography. If the final adjustment is performed on a later date, use V53.1, fitting & adjustment of other device: spectacles & contact lenses. The supporting documentation must be contained within the medical record.

Coding for the Eye Technician When the eye technician provides services for a patient in conjunction with an optometrist or ophthalmologist: – The eye technician is reported in the note as an additional provider using the designation paraprofessional. – Additional codes for any procedures the eye technician performs (e.g., spectacle ordering, visual fields) are to be reported.

Separate Eye Technician Encounters When an eye technician provides services at a separate encounter, the correct procedures (e.g., 99173, visual acuity screening) are entered in the CPT/HCPCS field. Example: Patient seen by an eye technician for vision exam portion of routine physical V70.5 2 Routine annual physical 99173 Screening test of visual acuity If an eye technician performs one of these procedures (99172 or 99173) at a separate encounter, no E/M level is assigned and one of these codes is assigned (see CMS section 6.12.4.5.).

Modifiers One of the most frequently asked questions deals with the use of the bilateral modifier when organs or body areas are paired, such as the eyes. This is particularly important in medical procedures (nonsurgical) in which a procedure is commonly performed on paired organs or body areas. The following table is essential to understanding the appropriate use of modifier 50 and modifier 52 in medical ophthalmological procedures.

CPT Codes with Modifiers CPT Code Sets for the Eye bilateral modifier? reducer modifier if on one eye? yes yes no no 92002 Ophthalmological services; intermediate, new patient X X 92004 Ophthalmological services; comprehensive, new patient X X 92012 Ophthalmological services; interm., established patient X X 92014 Ophthalmological services; comp., established patient X X 92020 Gonioscopy (unique code) X 92015 Refraction (determination of refractive state) X 92025 Computerized corneal topography X 92060 Sensorimotor exam - multiple measurements X X 92065 Orthoptic training X X 92071 Fitting of Contact Lens (CL) for ocular surface disease X X X X X 92072 Fitting of CL for management of keratoconus 92081 Limited Visual Field (VF) exam X X 92082 Intermediate VF exam X X 92083 Extended VF exam X X 92100 Serial Tonometry -multiple measurements X X Min 3 diff times in 1 day

CPT Codes with Modifiers CPT Code Sets for the Eye bilateral modifier? yes no Optical Coherence Tomography (OCT), anterior segment, with interpretation & 92132 report 92133 OCT, optic nerve with inter. & report 92134 OCT, retina with interpretation & report 92136 Interferometry with IOL calculation 92140 Provocative test for glaucoma 92225 Extended ophthalmoscopy w/ drawing Extended ophthalmoscopy w/ drawing 92226 subsequent Remote imaging for detection of retinal 92227 disease Remote imaging for monitoring / 92228 management of active retinal disease 92230 Fundus Fluorescein Angiography (FFA) 92235 FFA multi-frame imaging 92250 Fundus photography X x x X X X reducer modifier if on one eye? yes no x x x X X X X X x x X X X X X X

CPT Codes with Modifiers CPT Code Sets for the Eye bilateral modifier? reducer modifier if on one eye? yes yes no no 92260 Ophthalmodynamometry X X 92265 Needle oculoelectromyography X X 92270 Electro-oculography X X 92275 Electroretinography (ERG) X X 92283 Color Vision exam, extended X X 92284 Dark adaptation X X 92285 External ocular photography X X 92286 Endothelial cell imaging and analysis X X 92287 Anterior segment imaging with FA X X 92310 Contact Lens fitting, both eyes X X

CPT Codes with Modifiers

Additional CPT Procedure Codes Supplemental services include the following: Closure of the lacrimal punctum, by plug, each Corneal debridement 68761 either 65435 or 65436 Corneal scraping 65430 Dilation and irrigation of lacrimal punctum (CPT-4 code 68801) 68801 Epilation 67820 Extended ophthalmoscopy 92225 Fundus photography 92250 Out-of-office call (requires justification letter) 99056 Removal of foreign body Unlisted service or procedure 65205, 65210, 65220, 65222, 67938 92499

Initiation of Diagnostic and Treatment Program Prescription of medication(s) or lenses Arranging special ophthalmological diagnostic or treatment services (VF, OCT, FA) Consultations (PCP, specialist, sub-specialist) Laboratory procedures Radiological services

Special Ophthalmological Services Services in which a special evaluation of part of the visual system is made, which goes beyond the services included under general ophthalmological services, or in which special treatment is given. For example: VF, OCT, pachymetry, gonioscopy Special ophthalmological services may be reported in addition to the general ophthalmological services or evaluation and management services.

Special Ophthalmological Services Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Technical procedures (which may or may not be performed by the physician personally) are often part of the service, but should not be mistaken to constitute the service itself.

Refraction 92015: Determination of refractive state. Includes specification of lens type (monofocal, bifocal, other), lens power, axis, prism, absorptive factor, impact resistance, and other factors. Is billed in addition to the exam code. Medicare does NOT cover refraction.

Optical Coherence Tomography Codes 92132: Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral 92133: Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve 92134: Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

OC Tomography CPT Coding You CAN bill for 92132 (anterior segment OCT) on the same day as either – 92133 (ONH) or 92134 (Retina) You CAN NOT bill for 92133 and 92134 on the same day, even if you have two different diagnoses

Visual Fields 92081: Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent)

Visual Fields 92082: Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)

Visual Fields 92083: Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2

Remote Imaging CPT Codes 92227: Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral 92228: Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral Do not report 92227 in conjunction with 92002-92014, 92133, 92134, 92250, 92228 or with the evaluation and management of the single organ system, the eye, 99201-99350

Procedures Considered as Part of the 92 Series Eye Examination None of these procedures can be reported separately: *Laser interferometry *Potential acuity meter *Keratometry *Exophthalmometry *Transillumination *Corneal sensation *Tear film adequacy *Pachymetry *Schirmer's tear test *Slit lamp biomicroscopy *History *General medical observation

So How do the Codes Compare? 99 E/M vs. 92 Eye Codes (CMS 2014) CPT wRVU 99201 0.48 99202 0.93 99203 1.42 99204 2.43 99205 3.17 CPT wRVU 92002 0.88 92004 1.82

So How do the Codes Compare? 99 E/M vs. 92 Eye Codes (CMS 2014) CPT wRVU 99211 0.18 99212 0.48 99213 0.97 99214 1.50 99215 2.11 CPT wRVU 92012 0.92 92014 1.42

92 (Eye) Series vs. 99 (E/M) Series As you can see from the CPT wRVU series charts: – New patients intermediate level 2 coding have similar RVU’s (both Eye and E/M codes) – A new patient under 99 E/M code- comprehensive level 4 has a higher RVU value – An established patient has a higher intermediate RVU value under the 92 Eye series – A comprehensive established patient has similar RVU values

Summary CPT coding is important for workload capture. This module reviewed many of the common Eye CPT codes you will use on a daily basis. General guidelines have been provided for the 92 versus 99 series codes. For other CPT codes such as ordering lab tests, CT scans, MRIs and other activities, review CPRS procedure codes for those procedures you may request. For Low Vision codes refer to Patti Fuhr’s module.

In Summary Your Labor Mapping must be correct!! DSS RVUs must be set up correctly for your station and clinic. Data must be documented correctly and Timely!! Module 2) (See Review your data regularly wRVUs depend on CPT codes, and all procedures must be documented in encounters Review your OPES reports ICD-9 coding is covered in the next module

References MHS Coding Guidance: Professional Services and Specialty Coding Guidelines, Version 3.6, March 2013, pages 103-111. http://www.tricare.mil/ocfo/ docs/MHSProfessionalServicesSpecialtyCodingGuidelines.docx Centers for Medicare & Medicaid (CMS) Services Regulations & Guidance http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html Principles of CPT Coding, fifth edition, American Medical Association, copyright 2007, Chapter 9, pages 428-433. http:// www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insura nce/cpt/about-cpt/category-iii-codes.page Federal Service Optometry Coding Guide version 2.0 CPT Guide http://www.tricare.mil/ocfo/ docs/W-1-1400 Ophthalmology Optometry Final.ppt John Hopkins Medicine, 2009 HEDIS measures http://www.hopkinsmedicine.org