Sruthi Arepalli, MD: Uveitis has a reputation of bringing in less money than other traditionally more lucrative subspecialties, but I’d like to discuss how that might not be true.

Lana Rifkin, MD: Uveitis can be profitable. I don’t operate at all and make a comfortable living. The difference is really you have to bill smart. Uveitis has more complicated patients. Most uveitis specialists bill at Evaluation & Management (E&M) level 3 (“expanded problem focus”) or 4 (“detailed”), and that’s how we’re able to maintain our billing while seeing fewer patients. Our patients are very complicated and take a lot more time, but because of the new billing rules, I find that we are compensated more appropriately.

Eric Crowell, MD: I agree. The eye codes for follow-up visits, 92014 and 92012, reimburse more on average than an E&M 3 99213 code, so I use my eye codes more for those visits. Depending on your area, sometimes a new E&M 3 will pay more than the intermediate 92002 eye code. So, overall, I typically don’t use the E&M 3 code, just the eye codes and E&M level 4 and level 5 (“comprehensive”), because they reimburse more. If I am going to bill a level 3, I will likely bill an intermediate eye code because those typically reimburse more than a level 3. I mostly use those 2 eye codes and a level 4 and a level 5. We do a lot of clinic procedures, injections, and imaging, and while a good portion of imaging is the technical component, that can’t really go toward our collections; the physician component for that adds up over time. Knowing how to correctly bill for those is important. You also need to know what indications you can bill for, because that can sometimes be an issue, especially with Medicare. You might use the wrong ICD-10 code for an optical coherence tomography (OCT) and not get reimbursed.

SA: Could you expand on the different types of billing systems, as well as how to bill for different types of images? What are some key points for someone who’s starting out and building their practice?

EC: Eye codes are actually harder to bill with anymore because you have to make sure you get all those points in your History of Present Illness (HPI), do the full review of systems, and do a complete eye exam if you’re billing a comprehensive eye code. However, the E&M code is much more about what our assessment and plan is rather than the physical exam. It’s important to still record all of the information about the exam, but the billing is more focused on the medical decision making. So, if you’re going to bill an eye code, make sure you check all those boxes, because they are still important, but for E&M codes, it’s more of an algorithm.

LR: There are some simple things that you can do to make sure that you’re at least at level 4. A new patient, for example, is always a level 4 if not a level 5, because you’re either going to review 3 different tests or notes or you’re going to order at least 3 different tests. Also, everything in uveitis is vision threatening, and that’s key. That has to go in your assessment and plan. Everything is a “smart phrase” to me, and that really saves me on audits because I document everything. I have a smart phrase that’s “risk of vision loss with repeated flares,” because that’s true. Even if it’s something minor, there is a risk of vision loss with repeated flares and/or undertreatment. So, every one of my patients gets that phrase noted in their assessment and plan.

Reaching level 5 is not too difficult. In addition to reviewing/ordering at least 3 labs, you just have to document communication with another physician, which we do all of the time. Uveitis is unique in that we work with so many other subspecialties, so we can get to level 5 because of that communication. It has to be a 2-way communication (via phone, email, clinical message), and it has to be someone outside of your tax ID. That’s very important to know: if you’re communicating with one of your partners, that doesn’t count for level 5. However, if you’re talking to a referring optometrist or a referring ophthalmologist or any other physician from a different practice that’s not in your tax ID, that works. Just sending a letter does not count; it has to be a 2-way communication.

EC: Also, if you’re managing your own medications, that often will push you up to that level 5, as long as you’re ordering labs at those visits as well.

LR: Yes. High risk and management is level 5 if you’re seeing the patient every 3 months and ordering labs. Again, use a smart phrase because auditors don’t necessarily understand, for example, “continue methotrexate.” If you say, “high-risk medication management, labs reviewed” and they can see that you’ve ordered new labs, that meets the criteria for high-risk medication monitoring. That’s automatically a level 5, but you do have to see that patient every quarter.

EC: I agree that smart phrases are key. Also, when it comes to communicating with another physician, the communication doesn’t have to be the same day as the appointment; it can be a couple of days after. The other thing we haven’t really touched on is time. Mostly we don’t bill on time because we are at level 4 and 5 based on our own thinking. However, there are patients who ask enough questions that we’ve spent the 46 minutes together and then we’re at a level 5. Again, I’ll use a smart phrase there, such as “time spent with the patient, counseling, care coordination.” Charting and doing tests count, but it must be time that you yourself have spent, not time that techs or residents have spent.

LR: I do sometimes end up billing for time, for the same reason. When a patient has a ton of questions and notes, that takes time to review, and I should be compensated for that. My smart phrase for that would list the number of minutes spent coordinating care, reviewing the patient chart, and reviewing any outside imaging. That can easily reach level 5.

SA: Thank you both — those are excellent pointers. Let’s transition slightly to billing for tests in particular. As a physician, I rely heavily on imaging for myself and explaining pathology to my patient. But for new patients, I’ve learned that you can’t bill for every test. What is your strategy for that?

EC: We always do what we need to do for the patient. I do like to order tests right away, and sometimes I need that for academic and teaching purposes, and you can’t technically bill if it’s just for academic purposes. Per Medicare guidelines, you are not supposed to order tests until after you’ve examined the patient. For many of us that’s not how our patient flow works, and we know we want to see a test before seeing the patient. I order what I need when I need it.

LR: I’m in private practice 4 days a week, and in academic practice 1 day a week. My practice pattern is different for the two. In private practice, I pay for every test before I get reimbursed. So that really makes me stop and think about whether I need an OCT on every iritis patient, for example, because I’m not going to get paid for it unless I find something in the posterior segment. In private practice, if I can’t explain the vision in any way, I will take the risk of ordering a test that I might not get paid for.

You also should be very familiar with which codes will be reimbursed. I also consider bundling. Fundus photos and OCT cannot be billed on the same day. Very often I will have a patient with panuveitis and cystoid macular edema. I’d love to get a fluorescein angiography (FA), a fundus photo, and an OCT, but that’s not going to be paid for at the same time. What I often do in private practice is order an OCT and then have the patient come back for an FA at the following visit. In my academic practice, I can order anything, but in private practice I do stop and think.

EC: Payment also may depend on your personal compensation model. Like Dr. Rifkin, some physicians might be charged for tests, because that’s someone’s time. I’m not ever charged for that in an academic setting.

LR: Yes, for every OCT I order, it’s $8 for that person’s time. If that test isn’t paid for, that’s $8 out of my pocket.

SA: That’s really helpful to know. I’d also like to touch on modifiers and the most common ones that are used. What tips do you have regarding these?

LR: Modifiers 24 and 25 are the modifiers that I find most useful. A lot of our patients get injections or procedures done on the same day. Technically you can’t bill for a procedure if you’re doing it for the same diagnostic code. This means that often you have a patient on high-risk medication monitoring who has retinal edema for something else. They really are a level 5, but it’s important to associate the right thing to the right code. In that case, if I am going to bill a level 5 for my high-risk medication monitoring, that’s when I use Modifier 25 and I associate my periocular injection to retinal edema.

Modifier 24 is also important. I discovered this a couple years ago when I was reviewing my billing at Tufts and I noticed I was not getting paid for some patients. We see a lot of patients who are postoperative for someone else. So, if the biller doesn’t know who we are or what we do, they will bill our visit as part of the global surgical period, and then we don’t get paid for that. That’s unfair, because we didn’t do that surgery, yet we spent the time with that patient. We should be paid at least at level 4 or level 5. So, it’s very important to know that when you’re seeing these patients in a global surgical period for another surgeon, you need to use modifier 24 so that the biller knows that this is not your surgery, that you’re being consulted, and it’s your time, because you deserve to be compensated for that.

EC: I have two points to add to that. First, for Modifier 24, don’t use the code that the surgery was associated with or any of the ICD-10 codes that the surgery was associated with, or it will not be reimbursed. Make sure you’re using a different diagnosis. This is logical, because typically you’re not having surgery for uveitis, you’re having surgery for the cataract or something else.

Modifier 25 is for minor procedures, and Modifier 57 is very similar to 25, but it’s for major procedures, like a YAG or a cataract surgery. You can use Modifier 57 with all of the same diagnoses if it’s their first visit to you and they’re a new patient. For an established patient, you have to separate all of those codes out and associate them differently.

SA: Thank you both for this wealth of information. We’ve covered a lot. Do you have any tips for starting or maintaining your practice in terms of keeping organized or up to date on codes, and reviewing your charts to see if you’re getting paid appropriately?

EC: Actually, I have done this over the past year and a half. We’ve started completely from scratch. Some of it depends on how you’re set up. We have billers and coders who review all of that with us. I was on a 6-month probation period to make sure I was doing it right. Also, you probably will fail at some point, because the billing rules change periodically.

All of the ICD-10 codes are updated in October and then in January is when new rules will typically take effect for the actual coding itself for Medicare. Those are the important dates to watch for. Changes are announced on the CMS website, so it’s good to go and look at the website at those points. The American Academy of Ophthalmology is also good about updating the membership on what has changed to make sure that members are staying in compliance.

As for staying organized: stay organized. Customize your electronic medical record (EMR). Use your smart phrases. Make your EMR work for you, not the other way around. I think a lot of physicians work for their EMR rather than the EMR helping them with their clinic and billing flow. It takes time to customize an EMR, but once you’ve invested that time, you don’t have to do it at every exam. It’s an upfront investment that pays dividends in the long term.

LR: I completely agree. Tufts just switched to EPIC a couple of months ago, but Ophthalmic Consultants of Boston has used EPIC for years. When Tufts switched, I spent several hours and copied over every single one of my smart phrases. I knew that if I invested that time, it would make me so much more efficient in the long run.

Set up your smart phrases exactly how you will use them. You know your practice better than anyone. You know exactly what you do and how you do it. I know that I always review 3 labs or more or order 3 labs or more. I note that, and I add my smart phrase about how the risk of recurrence is vision threatening. That goes in my smart phrase every single time. It saves so much time, and it becomes second nature.

As far as staying up to date, there are a lot of groups on social media for new grads and younger physicians who are starting out, and there are a lot of people who have been in practice for a while who are so willing to help. Do not be afraid to seek out people who have done this before, they are more than willing to help, and there are many avenues by which to seek help. Don’t be afraid to ask. RP