3/12/2018

Mastering Retina Coding

ASRS – The Business of Retina
Dallas, Texas
Sunday, March 11, 2018
Joy Woodke, COE, OCS

1
 3/12/2018

Financial Disclosure
Joy Woodke, COE, OCS

o This presenter does not have a financial interest or relationship to

disclose relative to this activity.

o NOTE: Ms. Woodke has disclosed that she serves as an AAOE

Codequest Instructor and Consultant.

2
 3/12/2018

Retina Coding & Billing

• Become a master coder –

Appropriately maximize reimbursement

and….
Protect your revenue from recoupment

3
 3/12/2018

Effective April 2, 2018

• New OCS competency exam unique to Retina
• 100 multiple choice questions
• Open book
• 10 working days to complete
• 80 percent accuracy to pass/retest every 3 years
• Master coder can take both OCS and OCSR exams
• Practice test and additional questions - aao.org/ocs

4
 3/12/2018

Master Coder Checklist

➢ Understand the essential topics
➢ CPT, ICD-10, modifiers, global periods, compliance, CCI edits

➢ Identify retina coding resources

➢ Review insurance policies
➢ Stay current with coding changes
➢ Monitor audits and lessons learned
➢ Become the master coder

5
 3/12/2018

ESSENTIAL TOPICS
Master the Fundamentals of Retina Coding

6
 3/12/2018

Master Modifiers

7
 3/12/2018

Modifiers – Do You Know?

• Do you know how to bill an exam during a global period that is
unrelated to the surgery?

• Do you know how to bill a surgery during a global period that is

unrelated or complication a of the original surgery or preplanned or
therapeutic treatment?

• Do you know a modifier is required for the exam when a major

surgery that will be performed in the next 24-72 hours?

• Do you know how to bill for a more extensive surgery performed in

the global period of the original surgery?

8
 3/12/2018

Master Modifiers
• Modifiers can be appended to
o Office visits
▪ -24, -25, -57
o Diagnostic testing services
▪ -RT, -LT, -TC, -26, -50, -59
o Surgery
▪ -50, -54, -55, -58, -59, -78, -79, -RT, -LT

• Appropriate use can avoid denials

9
 3/12/2018

24 25 57
Significant, separately,
Unrelated evaluation and identifiable evaluation and Decision for
management service (or eye management service (or eye surgery, major
codes) by the same physician codes) by the same physician on procedure
during a postoperative period the same day of the procedure or
other services

Office visit in the Office visit same day

postoperative period is not Office visit same day,
related to the original as a minor surgery or within 3 days of a
major surgery (90
surgery:
(0 or 10 global day global period)
-New symptoms
-Significant changes in eye
period days)
health requiring new
evaluation
-Different diagnosis than the
surgery does not necessarily OFFICE VISIT
mean unrelated
MODIFIERS

10
 3/12/2018

58 78 79
1. Lesser to greater Unplanned return to Unrelated procedure
2. Pre-planned and documented as operating room during during the post-op
staged the post-op period period
3. Therapy following a major surgery

UNPLANNED PLANNED OR
PLANNED OR UNPLANNED
UNPLANNED
RELATED
UNRELATED
RELATED

NEW POSTOP PERIOD

DOES NOT BEGIN NEW POSTOP PERIOD
NEW POSTOP PERIOD

70% ALLOWABLE 100% ALLOWABLE

100% ALLOWABLE

SURGERY
MODIFIERS

11
 3/12/2018

Modifier Mayhem
• Do not append surgery modifiers to testing services
92134-79

92235-58

• Do not append office visit modifiers to surgeries

67028-25

67108-57

• Do not append eye modifiers to office visits

92004-RT

99214-LT

12
 3/12/2018

Test your Knowledge

• A modifier is required to bill a diagnostic testing
service performed during a global period

A. True
B. False

13
 3/12/2018

Test your Knowledge

• A modifier is required to bill a diagnostic testing
service performed during a global period

A. True
B. False

14
 3/12/2018

Test your Knowledge

• During the postoperative period of a PRP laser in the left
eye, the patient is seen for a retinal tear in the right eye
Diagnosis: Retinal tear, multiple breaks right eye
Select the correct coding:

A. 92XXX or 99XXX – 79
B. 92XXX or 99XXX – 24
C. 92XXX or 99XXX – 25

15
 3/12/2018

Test your Knowledge

• During the postoperative period of a PRP laser in the left
eye, the patient is seen for a retinal tear in the right eye
Diagnosis: Retinal tear, multiple breaks right eye
Select the correct coding:

A. 92XXX or 99XXX – 79
B. 92XXX or 99XXX – 24, opposite eye, note: ICD10
C. 92XXX or 99XXX – 25

16
 3/12/2018

Test your Knowledge

 During the global period of a repair of RD with

silicone oil, right eye, (67108) a patient is
scheduled for an unplanned removal of SO.

 Diagnosis: Mechanical complication due to

other implant and internal device, right
 ICD-10: T85.398A

17
 3/12/2018

Modifier Review
• Procedure: 67036-RT
• What modifier should be used?

o-78
o-79
o-58

18
 3/12/2018

Modifier Review
• Procedure: 67036-RT
• What modifier should be used?

o-78 unplanned procedure during global, related

o-79
o-58

19
 3/12/2018

Correct Coding Initiative (CCI)

20
 3/12/2018

Understand CCI Bundles

• Correct Coding Initiative (CCI)
• Bundled services performed the same day
• CCI edits effect the following in various combinations
o Exams can be bundled with other exams
o Exams can be bundled with tests
o Tests are often bundled with other tests
o Tests with surgery bundles
o and surgery with other same day/same session surgery

21
 3/12/2018

CCI EDITS =
Same Surgeon
Same Patient
Same Day
Same Session
Same Surgical Site
Note: CCI NOT applicable during global period

22
 3/12/2018

Correct Coding Initiative - FAQS

• What happens when two bundled codes are billed?

• Can the -59 modifier be used to unbundle?

• How often are CCI edits updated?

• Where can I find CCI edits?

23
 3/12/2018

Test Your Knowledge

• New patient is seen for a comprehensive eye evaluation.
• Initial extended ophthalmoscopy is performed in the right
eye, diagnosis vitreous hemorrhage.
• Initial extended ophthalmoscopy is performed in the left
eye, diagnosis diabetic macular edema.
• Intravitreal injection is performed in the left eye for DME.
• Type 1, mild retinopathy
• Who is the payer? Medicare Part B.

24
 3/12/2018

Test Your Knowledge

• Select the correct coding and ICD-10 code:

a. 92004 E10.3212, H43.11

92225-XS-59-LT E10.3212
92225-XS-59-RT H43.11
67028-LT E10.3212, H43.11
b. 92004 E10.3212, H43.11
92225-XS-RT H43.11
67028-LT E10.3212

25
 3/12/2018

Test Your Knowledge

• Select the correct coding and ICD-10 code:

a. 92004 E10.3212, H43.11

92225-XS-59-LT E10.3212
92225-XS-59-RT H43.11
67028-LT E10.3212, H43.11
b. 92004 E10.3212, H43.11
92225-XS-RT * H43.11
67028-LT E10.3212 Note: ICD10 laterality

*ophthalmoscopy bundled with retina procedures effective 7/1/2013

26
 3/12/2018

Test Your Knowledge

• Pars plana vitrectomy is performed with PRP endolaser
and membrane peeling, left eye
o 67040, 67041
• Diagnosis:
• Type 2, Proliferative Diabetic retinopathy without edema
o E11.3592

• Epiretinal membrane
o H35.372

27
 3/12/2018

Test Your Knowledge

• Pars plana vitrectomy is performed with PRP endolaser
and membrane peeling, left eye
o 67040, 67041
• Diagnosis:
• Type 2, Proliferative Diabetic retinopathy without edema
o E11.3592

• Epiretinal membrane
o H35.372

28
 3/12/2018

Test Your Knowledge

• Select the correct coding:

a. 67040-LT
b. 67041-LT
c. 67040-LT, 67041-59-LT

29
 3/12/2018

Test Your Knowledge

• Select the correct coding:

a. 67040-LT
b. 67041-LT
c. 67040-LT, 67041-59-LT

30
 3/12/2018

Vitrectomy Surgery
• RVUs:

CPT 2018 2017 2016 2015 2014

CODE

67041 32.85 32.66 32.66 32.63 38.71

67040 29.73 29.59 29.56 29.51 41.38

• Coding error billing 67040 – difference @ $112

31
 3/12/2018

Global Periods

32
 3/12/2018

Global Periods
• The global periods vary by surgery and by insurance carrier
• Medicare 10 day global period = 90 day global period for
some insurance carriers
• How can you confirm the global period?
o RVU / allowable

33
 3/12/2018

Global Periods
• Minor procedure
o Global period – 0 or 10 days
o Examples
▪ Repair RD, cryo 67101 10 day global
▪ Intravitreal injection 67028 0 day global

• Major procedure
o Global period – 90 days (Medicaid is often 45-90)
▪ Vitreous tap 67015 90 day global
▪ Repair RD, vx, 67108 90 day global
▪ Laser to rep ret tear 67145 90 day global

34
 3/12/2018

Laser Global Period Grid

Medicare Same Day Commercial Same Day
CPT code Office Visit Office Visit
Global Modifier
Global* Modifier

66761 Yag PI 10 days -25 90 days -57

66821 Yag PCO 90 days -57 90 days -57
67105 Laser repair RD 10 days -25 90 days -57
67145 Laser repair 90 days -57 90 days -57
retinal tear, prophylaxis RD
67210 Focal laser 90 days -57 90 days -57
67220 Laser for choroid 90 days -57 90 days -57
lesion, CNV

67228 PRP laser 10 days -25 90 days -57

* Confirm global period per
insurance carrier based on
allowable and/or RVU

35
 3/12/2018

25 57
Significant, separately, identifiable
evaluation and management service Decision for surgery,
(or eye codes) by the same physician major procedure
on the same day of the procedure or
other services

Office visit same

Office visit same day day, or within 3
as a minor surgery (0 days of a major
or 10 global period surgery (90 day
days) global period)
Medically
necessary?

36
 3/12/2018

CODING UPDATES
Master and Track Changes in Retina Coding

37
 3/12/2018

Hot Topics in Retina

• MUE edits – bilateral procedures
o Medicare Part B
o 67028-50, not 67028-RT, 67028-LT

• Commercial payers
o Frequency edits for eye visit codes

• New Retina Taxonomy Codes

o New patient rules in ophthalmology still apply

• ABNs for injections

o Covered service, not necessary

38
 3/12/2018

ICD-10-CM

39
 3/12/2018

ICD-10-CM Updates
• Effective Oct 1, 2017
• 50+ new ICD-10 codes affecting ophthalmology went
into effect Oct. 1, 2017
• The most significant updates expand the codes for vision
rehabilitation and myopic degeneration
o Download copies of decision trees at aao.org/icd10

40

40
 3/12/2018

Myopic Degeneration
• January 2017 FDA approved Lucentis as a treatment for
patients with choroidal neovascularization (CNV or
mCNV) resulting from myopic macular degeneration
(MMD)
• No change in the drug units – 5 units
• Documentation should include any residual drug
discarded

41

41
 3/12/2018

ICD-10-CM Decision Trees

aao.org/icd10

42
 3/12/2018

Myopic Degeneration
• Intravitreal injection of Lucentis for mCNV, right eye
• Correct coding
• 67028-RT
• J2778, 5 units
• Diagnosis: H44.2A1

43
 3/12/2018

Insurance Policies

44
 3/12/2018

Medicare
• Local Medicare Administrative Contractor (MAC)
o Local Coverage Determination (LCD)
▪ Draft
▪ Active
o Local Coverage Articles

• CMS – National Coverage Determination (NCD)

• Your Resource for MAC LCDs -
aao.org/lcds

45
 3/12/2018

Medicare LCDs
First Coast
• 92134 – SCODI Retina States: PR,
VI, FL
• First Coast – new policy effective 1/2018
o Frequency
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
 1 month = 30 days?
▪ Drug related (CQ and/or HCQ) – baseline examination within the first
year and annual follow-up after five years of treatment. Higher-risk,
annual testing may begin immediately (without a 5-year delay).

46
 3/12/2018

Medicare LCDs
Palmetto
States: VA,
• 92134 – SCODI Retina NC, WV, SC,
AL, GA, TN
• Palmetto – new policy effective 2/2018
o Frequency
▪ Performed at clinically reasonable intervals
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
 Generally not require SCODI more than once per month
▪ Drug related (CQ and/or HCQ) –
 Baseline exam first year of commencement if any macular abnormalities
are present
 Annual screening beginning at the 5th year of exposure to drug

47
 3/12/2018

Medicare LCDs
Novitas States:
• 92134 – SCODI Retina TX, CO, OK,
MS, NM, LA,
AR, DC, PA, DE,
• Novitas – new policy effective 1/2018 NJ, MD
o Frequency
▪ One exam every 2 month manage primary retina conditions
▪ Active treatment (AMD, CNV, DR, ME) – no more than one (1) exam
per month will be considered medically reasonable.
 1 month = 30 days?
▪ Drug related (CQ and/or HCQ) – baseline examination within the first
year and annual follow-up after five years of treatment. Higher-risk,
annual testing may begin immediately (without a 5-year delay).

48
 3/12/2018

Medicare LCDs
CGS States:
• 92134 – SCODI Retina OH, KY

• CGS – new policy effective 10/2017

o Frequency
▪ No more than 4 tests per year with exceptions
▪ Active treatment (AMD, CNV, DR, ME) – monthly
▪ Rapid clinical changes requiring therapy and follow-up (macular hole,
TRD) - monthly
▪ Drug related (CQ and/or HCQ) – baseline examination within the first
year and annual follow-up after five years of treatment. Higher-risk,
annual testing may begin immediately (without a 5-year delay) or with
other risk factors

49
 3/12/2018

Medicare LCDs
NGS States:
VT, ME, NH, NY,
• 92134 – SCODI Retina MA, RI, CT, MN,
WI, IL
• NGS – new policy effective 10/2017
o No frequency language
o Limitations of coverage
▪ Absence of an indication
▪ Screening

50
 3/12/2018

Medicare LCDs
Noridian States:
• 92134 – SCODI Retina UT, AK, WA, AZ,
ND, SD, OR,
• Noridian – new policy effective 10/2017 MT, ID, WY, NV,
GU, HI, CA
o Intraocular Avastin
o Frequency
o 92134 is appropriate at 4-6 week intervals

• Cahaba – no policies
o Transitioned to Palmetto, 2/2018

51
 3/12/2018

Medicare LCDs
WPS States:
• 92134 – SCODI Retina IN, MI, KS,
NE, MO, IA
• WPS – new policy effective 9/2017
o Frequency
▪ One exam every 2 month manage primary retina conditions
▪ Active treatment (AMD, CNV, DR, ME) – may be allowed one (1)
scan per month will be considered medically reasonable.
▪ Rapid clinical changes requiring therapy and follow-up (macular hole,
TRD) – monthly
o Limitations of coverage – same day
▪ 92250, 92225 *, 92226 *, 76512 *
*not CCI bundled with OCT – limitations in LCD. Documentation must justify the procedures

52
 3/12/2018

Medicare NCDs
• 67221 – PDT
o MACs - No active LCDs
o Active NCD – 80.3.1
▪ Predominately classic subfoveal choroidal neovascularization (CNV)
lesions (where the area of classic CNV occupies ≥ 50% of the area of
the entire lesion) at the initial visit as determined by a fluorescein
angiogram (FA).
 3 months prior to treatment
▪ Subsequent follow-up visits require either an optical coherence
tomography (effective April 3, 2013) or an FA (effective April 1, 2004)
to access treatment response.

53
 3/12/2018

Commercial Carriers
• Aetna policy
o Nd: YAG laser
o Laser vitreolysis for treatment of vitreous degeneration and
vitreous floaters
▪ Experimental and investigational

54
 3/12/2018

Audits

55
 3/12/2018

Audits

• Tips for success

o Quote the insurance policy or LCD
o Show documentation requirements were met
o Have invoices and inventory logs readily available
o Conduct internal audits on billing accuracy
o Reference coding principles and medical journals
o Send abbreviation list and signature logs
o Meet the deadlines, or ask for extension!

56
 3/12/2018

Stay of the Radar

• “For our office, a typical claim the day of an injection

is”:
o 92014 Comprehensive Eye visit code
o 67028 Intravitreal injection
o JXXXX Drug
o 92134 Retina OCT
o 92235 Fluorescein angiography
o Occasionally 92226 Subsequent ophthalmoscopy

• Take away – consider medical necessity, frequency edit

requirements and CCI bundles

57
 3/12/2018

Audits
• TPE: Targeted Probe and Educate
o MAC audits
▪ Three rounds with education
▪ Continue with high denial rates
 extrapolation,
 referral to the Zone Program Integrity Contractor (ZPIC) or Unified
Program Integrity Contractor (UPIC),
 referral to the RAC,
 100% pre-pay review, etc.

58
 3/12/2018

Audits
• TPE: Targeted Probe and Educate
o Targets
▪ Subsequent hospital care
▪ Emergency room visits
▪ Subsequent nursing facility care
▪ Correct place of service

59
 3/12/2018

Test your Knowledge

• A new patient who is in the hospital is transported to our
office for an examination. They are then transported
back to the hospital. How is the claim submitted?
1. Office exam, POS 11 (office)
2. Hospital exam, POS 21 (hospital)

60

60
 3/12/2018

Test your Knowledge

• A new patient who is in the hospital is transported to our
office for an examination. They are then transported
back to the hospital. How is the claim submitted?
1. Office exam, POS 11 (office)
2. Hospital exam, POS 21 (hospital)

61

61
 3/12/2018

Audits
• Supplemental Medical Review Contractor
(SMRC)
o Contractor – StrategicHealthSolutions, LLC
o Targeted areas
▪ Outpatient drug units
▪ Incorrect place of service
▪ Delegated testing services
 Orders

62
 3/12/2018

Audits
• Comprehensive Error Rate Testing (CERT)
o Contractor – AdvanceMed
o Request for medical records
o Meet the deadline!

63
 3/12/2018

Audits
• Recovery Audits (RA)
o Automated audits
▪ Driven by data
o Complex review
▪ Submit documentation

64
 3/12/2018

Audits
• Recovery Audits (RA)
o Automated audits – few examples
▪ Injections sooner than 28 days for all anti-VEGF drugs
 Including Avastin
 Medicare leeway is 25 days
▪ CPT code 67228 Treatment of extensive or progressive retinopathy
(eg, diabetic retinopathy) billed more than once per eye during the
global period
 Note for CMS now a 10-day global period
 Recovery auditor may not be aware
 Check your own performance for past 12 months

65
 3/12/2018

Code This Superbill

Be the Master Coder

66
 3/12/2018

Code This Superbill

• New patient is referred for a diabetic exam
o CC - floaters in the right eye, decrease vision over the last few
months in the left eye. Type 2 Diabetes, fairly controlled blood
sugar and BP. Last A1C around 9.

67
 3/12/2018

Code This Superbill

• New patient is referred for a diabetic exam
o Comprehensive history
o Comprehensive exam
o Moderate medical decision making
o Tests today – FA / FP / OCT, both eyes
▪ Tests ordered and interpretations documented
o Diagnosis
▪ OD Type 2 Diabetes, PDR without edema
▪ OS Type 2 Diabetes, mild NPDR without edema

68
 3/12/2018

Code This Superbill

• Plan
▪ Dilated diabetic exam performed today, letter to PCP and referring
provider
▪ Chart notes from referring physician reviewed
▪ PRP laser, right eye today
▪ Post-op visit in one week

69
 3/12/2018

Bonus: MIPS – Quality Program

• Annual Diabetic Eye Exam

• *MIPS quality measures met today

▪ IRIS 2 – DR: documentation of presence or absence of ME and level of severity of
retinopathy
▪ IRIS 3 – DR: communication with the physician managing ongoing diabetes care
▪ IRIS 6 – Diabetes: Eye Exam

• Additional eligible measures based on documentation

▪ IRIS 17 – Documentation of current medications in the medical record
▪ IRIS 14 – Preventive care &Screen Tobacco Use: Screening and Cessation Intervention

70
 3/12/2018

Code This Superbill

• What type of office visit?
• Modifiers?
• Diagnostic testing?
• CCI bundles?
• Laser?
• ICD-10?

71
 3/12/2018

Code This Superbill

• What type of office visit?
o E/M or Eye Code?
o What is the insurance? Medicare Part B
o 99204 or 92004

72
 3/12/2018

Code This Superbill

• Modifiers?
o Laser performed today
o -25 vs. -57 ?
o Global period
▪ Medicare – 10 days
o -25 modifier required for new patients? No.

73
 3/12/2018

Code This Superbill

• Diagnostic testing?
o FA / FP/ OCT, both eyes
o Bill unilateral vs. bilateral? Inherently bilateral
o -RT or –LT modifiers? No.
o CCI bundles? Yes, 92134 and 92250
o 92235, 92250, or
o 92235, 92134

74
 3/12/2018

Code This Superbill

• Laser?
o PRP, right eye
o 67228-RT

75
 3/12/2018

Code This Superbill

• ICD-10?
• OD Type 2 Diabetes, PDR without edema – E11.3591

76
 3/12/2018

Code This Superbill

• ICD-10?
• OS Type 2 Diabetes, mild NPDR without edema – E11.3292

77
 3/12/2018

Code This Superbill

• 99204 - E11.3591, E11.3292
• 92235 - E11.3591, E11.3292
• 92250 or 92134 - E11.3591, E11.3292
• 67228-RT - E11.3591

• Bonus question – what is the global period for PRP?

o Who is the payer? Medicare Part B
o 10 day global period

78
3/12/2018

79