CPT to ICD-10 code linkage is the first step toward accurate claim submission. Adding to that challenge is the reality that diagnosis coverage varies by payer. Along with mastering the complexity of retinal coding, the following five pearls are lifelines as part of any practice’s daily workflow.

1. MASTER THE PRINCIPLES OF CORRECT CODING INITIATIVE (CCI) EDITS.

When multiple CPT codes are performed on the same day, best practice is to review the CCI edits, published by Centers for Medicare and Medicaid Services (CMS), related to the codes. Remember, you must check every code combination. Tests are bundled with other tests. Tests are bundled with surgical procedures and surgical procedures are bundled with other surgical procedures. These edits are updated quarterly: January 1, April 1, July 1, and October 1. (See Table 1.)

• When is Unbundling Appropriate? Each bundling edit is identified with either a 1, indicating unbundling is allowed when criteria is met; a 0, indicating the two codes involved are mutually exclusive and can never be unbundled; or a 9, indicating the bundling edit was made in error and has been reversed. When unbundling is appropriate, append modifier -59 to the CPT code in column 2.
• Criteria for Unbundling. Documentation must support the following:
  • A different session
  • A different procedure or surgery
  • A different site or organ system
  • A separate incision or excision
  • A separate injury

Example: Laser used to repair a retinal lesion by photocoagulation (67210) and laser to repair progressive retinopathy by photocoagulation (67228) are bundled with modifier 1. Because different lasers are treating the same contiguous structures of the same organ, an appropriate example of unbundling these two codes would be if they were performed in opposite eyes. To unbundle the two codes, modifier -59 (or -XS if a Medicare patient) would be appended to the 67228. When bundled codes are incorrectly submitted to an insurance carrier, the CPT code with the lower allowable is typically paid. Verifying CCI edits prior to claims submission will ensure maximum reimbursement.

2. MONITOR THE RELATIVE VALUE UNIT (RVU) & ADJUST FEES AS NEEDED

Each year, the RVU value per CPT code may change. For example, at the beginning of 2017, the non-facility RVU for pneumatic retinopexy (67110) increased to 24.82 from 21.51 in 2016. Reviewing these changes annually and adjusting your usual and customary fees will guarantee that charges submitted aren’t below the carrier allowable.

3. RECOGNIZE CURRENT GLOBAL PERIOD PER CPT CODE

The global period for surgical procedures changes periodically. On Jan. 1, 2017, laser to repair a retinal detachment (67105) had a global period adjustment from 90 days to 10 days for Medicare carriers. Some commercial payers may update the global period, while others may remain at 90 days. The RVU value and reimbursement was also reduced to reflect the global period changes. Additionally, the “one of more sessions” language was removed from the CPT code description. As a result, if additional laser treatment is necessary outside the global period, the laser treatment can be billed again. Office visits also can be billed for follow-up visits outside of the 10-day global period.

4. IDENTIFY AND REVIEW INSURANCE POLICIES FREQUENTLY

Medicare Administrative Contractors publish local coverage determinations and CMS publishes national coverage determinations to provide policies and guidelines for correct coding for specific procedures. These policies designate medical necessity, approved diagnosis codes, diagnostic testing requirements, and frequency edits as applicable. Commercial carriers may also publish policies for various procedures and often provide them on their websites or in provider manuals.

5. MASTER THE PRIOR AUTHORIZATION PROCESS

Most Medicare Advantage and commercial plans require prior authorization for diagnostic or surgical procedures. Most important is to identify the carriers that require prior authorization for intravitreal injections and anti-VEGF medications. Some insurance companies won’t allow retroactive requests for authorization or they may require step therapy. Understanding these nuances will avoid the dreaded denial of a high cost medication.

MASTERING RETINA CODING

Retina coding is complex, but these five pearls will help you avoid claim denials and maximize reimbursement for procedures. NRP