The goal in clinic is simple — to provide the best possible care to patients. But making the right medical decision is only the beginning, because there are numerous other practice management challenges to face. Proper coding is a universal challenge, whether for an academic practice, a solo practice, or a single-specialty or multispecialty group practice. While it is not what drives retina specialists to practice medicine, coding remains a necessary evil to provide the care that patients need.

The current coding landscape lends itself to frequent changes, whether reimbursement determined by the Centers for Medicare and Medicaid Services (CMS), new or expiring Current Procedural Terminology (CPT) codes, quarterly changes to the National Correct Coding Initiative (NCCI) edits for multiple procedures, or International Classification of Disease (ICD) annual updates. With so many changes, it can be challenging for clinicians to achieve the true goal of coding — getting reimbursed for work performed: no more, no less.

This article aims to help navigate changes by first looking at recent CMS updates, delving into some challenging, but common coding scenarios, and looking toward some upcoming coding changes.

CMS CODING UPDATES

As CMS continues to try to control the rising cost of health care from government-sponsored programs, reimbursements are routinely evaluated, and generally reduced, in an effort to achieve cost containment. In 2019, office procedures such as subtenon injections and retrobulbar injections saw reductions in their relative work value units (RVUs), which is closely linked to reimbursement. Office diagnostics were also impacted, the most notable change being in coding of electroretinograms (ERGs). The single ERG code (92275) has been replaced by 2 new codes that offer additional granularity: full-field ERG (92273) and multifocal ERG (92274). With that update in mind, let’s look at some common coding scenarios.

COMMON CODING SCENARIOS

Diagnostics

A 52-year-old male patient is referred for possible central serous chorioretinopathy (CSR) vs age-related macular degeneration (AMD), and testing includes optical coherence tomography (OCT), fundus photography (FP), a fluorescein angiogram (FA), and indocyanine green angiography (ICG). The evaluation confirms a diagnosis of exudative macular degeneration, and appropriate treatment is initiated. Although there were 4 diagnostic tests, not all of them are reimbursed, per the NCCI edits. In this scenario, only an FA/ICG (92242) and an OCT (92134) can be billed. The codes for FP and FA/ICG are mutually exclusive, as are the codes for FP and OCT.

Some NCCI edits to keep in mind for diagnostics include the following:

• FP + OCT: Can bill for 1 or the other, but not both
• FA + FP + OCT: Can bill FA + FP or FA + OCT, but not all 3
• FA/ICG + FP + OCT: Can bill FA/ICG + OCT, but no other combination
• ERG has no conflicts with other imaging

Multiple Procedure Payment Reduction

When performing multiple tests, CMS implements the Multiple Procedure Payment Reduction (MPPR), which affects the second and subsequent tests that are billed. For example, due to the MPPR, diagnostic tests that have a technical component (technical value of time, expertise, and equipment necessary to perform the procedure) and professional component (diagnostic value by the physician evaluating and interpreting the test results) see reductions, albeit by differing amounts. In the above scenario, the FA/ICG would be reimbursed normally and the OCT would have the technical component reduced by 50% and the professional component reduced by 5%.

Modifiers

A 75-year-old female patient with exudative AMD in the right eye is undergoing a treat-and-extend protocol. These patients often present the most challenging coding scenarios, because of the concern of using a -25 modifier to bill for a concurrent exam with an injection. The -25 modifier is appropriate when a significant, separately identifiable evaluation and management service by the same physician is performed on the same day of the procedure or other service. Of note, the exam cannot simply be done to confirm the need for the procedure in question. In this example, applying the modifier to an eye code for the exam if simply confirming the need for an injection in the right eye is inappropriate. However, if the exam included an evaluation of dry AMD or new-onset floaters in the fellow eye, it would be acceptable.

Many physicians have been nervous to use the -25 modifier secondary to a number of audits due to coding abuses in recent years. Indeed, use of the -25 modifier has dropped substantially since it peaked in 2016. The key to correctly using the -25 modifier is documentation. Retina specialists should make sure there is a chief complaint specific to the fellow eye, document the full exam, and make a clear plan. Good documentation won’t prevent an audit, but it will allow the coding/billing to stand up to the scrutiny.

Procedures

A 65-year-old female patient is referred for flashes and floaters in the left eye. Testing includes visual acuity, intraocular pressure, visual fields to confrontation, slit lamp exam, and dilated exam of the posterior pole with scleral depression in both eyes. There are multiple areas of lattice in both eyes and a new PVD without evidence of a tear in the left eye. In this scenario, if a drawing is performed to document areas of lattice, an initial extended ophthalmoscopy (92225) can be billed per eye in addition to the evaluation and management (E&M) or eye code. Extended ophthalmoscopy has seen tremendous increase in utilization in recent years and has become an area of focus for audits due to misuse.

Type of Exam

A 68-year-old male with a 10-year history of diabetes mellitus comes in for evaluation due to blurry vision in the right eye. The retina specialist obtains a thorough patient history, checks vision, intraocular pressure, visual fields to confrontation, a slit lamp exam, and a dilated exam. Additional testing including an FA and OCT were performed due to the appearance of diabetic macular edema. How should the visit be billed?

Ophthalmology is unique in that there are multiple code sets available, including both the E&M codes and eye codes. There are several differences between E&M codes and eye codes. First, E&M codes have 5 different coding levels, whereas eye codes only have 2. Second, determining the appropriate E&M coding level requires input based on patient history, examination, and medical decision-making, whereas eye code guidelines are based on a 12-part exam for which criteria have been previously published.¹ Third, the reimbursement rates are different for the codes, because initial E&M visits typically pay more than initial eye code visits. One final thing to consider is that using the E&M codes may inadvertently list the ophthalmologist as the patient’s primary care physician when costs are attributed for accounting in the Merit-Based Incentive Payment System (MIPS). This would effectively unfairly make the ophthalmologist a high-cost physician accounting for care that was not actually provided. In our example, assuming a comprehensive history is taken, the exam performed would likely support a level 4 E&M (99204) code or a comprehensive eye (92004) code.

Upcoming Coding Changes

The 92225 (initial extended ophthalmoscopy) and 92226 (subsequent extended ophthalmoscopy) codes will be replaced by codes that better define the procedure in 2020. There are 3 major changes with the new codes. First, laterality will be eliminated, meaning whether the procedure is performed unilaterally or bilaterally, it can only be coded once. Second, there is a distinction between a posterior-pole exam + drawing (ie, optic nerve drawings or macula drawings) and peripheral exam + drawing (ie, lattice, tears, and so on). Third, the peripheral exam requires a scleral-depressed exam. Although both codes require a drawing, the codes will have differing reimbursements that will reflect the difference in physician time needed to perform the posterior-pole vs scleral-depressed peripheral exam.

Additionally, based on CMS’s guidance, the E&M codes are being re-evaluated. CMS initially put forward a proposal to collapse the 5 levels into 2, and more recently revised that to 3 levels. The American Medical Association is working on its own version, which would consolidate the E&M codes to 4 levels. Certainly this will be an area worth following, because significant changes to both proposals may still be coming. The number and scale of some of these changes only highlights the need to remain current with the ever-changing coding climate. RP

REFERENCE

1. Vicchrilli S. American Academy of Ophthalmology. E&M or eye codes? How to choose which to use. Available at: https://www.aao.org/eyenet/article/e-m-eye-codes-how-to-choose-which-to-use . March 2019. Accessed March 17, 2019.