AOA FAQ's

Prompt Pay Discounts

Q: We have been offering a 20% prompt pay discount for all office visit codes as well as procedures as long as that fee is paid on the day of service. We offer the same prompt pay discount to all insurance carriers as long as we are paid the same day of service. A 92015 refraction code is the only exception. Our normal fee for refraction is $80 and our same day discount is $30.  That discount exceeds our usual 20%.  Is that all right with Medicare and other payers?

A: I believe the prompt pay discount is actually a Federal Trade Commission issue, rather than anything related to insurance contracts or Medicare, per se.  Experts’ opinions on the maximum for prompt pay discounts range from 6% all the way up to 25%, so your current discount on your refraction charge would seem to be larger than most experts would recommend.  I recommend that doctors develop numbers that they believe to be appropriate for the value of the service, rather than what insurers or others will pay, so that discounts are less necessary and big discounts aren't necessary at all. [ Back to top ]

Overpayments from Secondary Insurers

A patient came in for a regularly scheduled exam, without a medical complaint or reason for the visit. He told us their vision plan would be primary, then to send it on to their medical insurer as secondary. The vision plan paid their part and then the medical paid much more than we expected. My staff returned the over payments to the patient, but I’m not sure how this should have been handled.

A: I hate to dodge any question, but I think this is purely a matter of contract. I would suggest that your office contact the vision plan’s provider relations first, as that should be easier than contacting the medical plan, to see how the vision plan views this question. Then, depending upon what the vision plan says, the patient should contact their medical plan. No matter what happens, I doubt that either company will want the patient getting the cash for the double payment. [ Back to top ]

Systemic Diabetes without Ophthalmic Manifestations

Q: I have a patient with background diabetic retinopathy, macular drusen, visually significant cataracts with decreased vision, and I run a retinal scan to look for foveal edema or SRNV, can I use the diagnosis codes of retinal edema and/or wet macular degeneration if the scan is negative?  A second example is a patient concerned about recent onset of flashes and floaters. Do I use retinal detachment as the diagnosis code since that is what I am looking for?

A:  It is inappropriate to use a diagnosis code unless the patient actually has the condition.  I would suggest using the diagnosis code for the conditions that the patient actually has, assuming that those diagnoses are germane to the day’s visit.  In your first example, you would report diabetic retinopathy and possibly macular drusen.  For the second example, you could use 379.24, vitreous floaters, with V80.2 as the second code, indicating you’re looking for other eye problems.  V80.2  is used to indicate you're looking for an ophthalmic condition other than glaucoma (V80.1 is used if you're looking for glaucoma).  Understand that some major medicals may not pay for screenings for medical conditions such as detached retina, no matter how you put it on the claim.  For that reason, you should carefully explain to the patient why the test is necessary and have them sign an Advance Beneficiary Notice prior to doing the test. That way, if the payer denies it, you'll be paid by the patient .[ Back to top ]

Same day: Comprehensive exam, refraction, and epilation for left upper lid. 92014, 92015, 67820 E1 Where does the -25 go

Q. This is a pretty basic coding question, but I can't seem to find the right resource to get this billed right. Same day: Comprehensive exam, refraction, and epilation for left upper lid. 92014, 92015, 67820 E1

Where does the -25 go to show that epilation was a separate service done the same day as exam to get paid for exam and epilation properly.

A. First, it has to be clear that the surgical procedure, 67820, is indeed separate from the office visit, as CPT makes it clear that each minor surgical procedure includes an office visit.  The medical record for the office visit would include details unrelated to the surgery.  For example, maybe the reason for the visit was something other than 'scratchy eye' or 'Those scratchy lashes have grown back.'  Maybe the patient is in for a glaucoma check up and you find lashes scratching the cornea during biomicroscopy.  The visit is billed with the glaucoma Dx code and the 25 modifier to indicate the visit is unrelated to the surgery. The 67820 is billed with the trichiasis Dx code. The epilation will not need a modifier in most cases. [ Back to top ]

When can you use 92000 office visit codes for Medicare and how often can these codes be used?

Q.When can you use 92000 office visit codes for Medicare and how often can these codes be used?

A. The 92000 office visit codes, intermediate or comprehensive, can be used any time the content of the patient's medical record matches the required elements in the CPT definition for the code.  The CPT definition for the comprehensive requires seven elements: case history, general medical observation, external examination, ophthalmoscopic examination (with or without mydriasis or cycloplegia), gross visual fields, basic sensorimotor examination and initiation of diagnostic and treatment program. There is no limit to how many times the 92000 codes can be used per year. The CPT definition for the intermediate requires six elements in the medical record: A new or previously existing problem, complicated by a new problem, case history, general medical observation, external/adnexal examination, other diagnostic procedures as indicated, and initiation or continuation of diagnostic and treatment program. [ Back to top ]

Problems co-managing cataract surgery with some insurances

Q. We are still having problems co-managing cataract surgery with some insurances.  They seem to pay us on a per visit basis, rather than based on the number of days we’re responsible for the patient’s post op care.

A. It sounds like the plan you’re referring to is a Medicare Advantage plan.  Because of the very broad language of the bill that created these plans, companies are free to do some things differently than straight Medicare Part B.  In Part B, of course, the surgeon applies the 54 modifier to the surgery code and notes in the patient chart that the patient is returned to the OD on a set date for post op care.  The surgeon is paid for that portion of the 90 days that she or he is responsible for.  The OD applies the 55 modifier and is paid for the days that he or she is responsible for the post op care.  Many Medicare Advantage plans have had little or no experience with the 54 or 55 modifiers, so tend to get creative in the way they pay for post op.  Ideally, doctors and staff would call the insurer and complain and explain right away so that the payer could choose to handle post op care just like Part B does.  I doubt much of that has happened.  Or, the plans have heard complaints and explanations and don't really care.  Because of the legislation, I doubt that the Centers for Medicare and Medicaid Services would try to do anything to rectify this, as long as the total payment to the OMD and OD would be no more than the total allowed for the surgery when the 54 and 55 modifiers are not applied.

So, what to do?  I guess the only option is to try to find a real live person at the company to speak with, ascertain what their policy for post op care actually is, explain what Medicare Part B's policy is and ask them to change it to match.  If they will not change to comply with Medicare’s policy, you will have to adapt to what they require.  The most common option I’ve seen is that the insurer requires the doctor to bill for each visit on a separate claim, using the appropriate office visit from the 99000 or 92000 series. [ Back to top ]

What are the best ICD-9 and CPT (e/m vs 920xx) codes to bill for ruling out toxicities to medications

Q. What are the best ICD-9 and CPT (e/m vs 920xx) codes to bill for ruling out toxicities to medications (i.e. plaquenil,and Interferon)

A.  We suggest using the ICD code for the condition (e.g. rheumatoid arthritis,) followed by V58.69 (long term use of high risk medications,) combined with the code of the class of the medication, e.g. E931.4 for Plaquenil. [ Back to top ]

Do we bill MC one way and private insurances (ie Anthem, UHC) another?

Q.  Do we bill MC one way and private insurances (ie Anthem, UHC) another? 

A.  I suggest following national rules; including Current Procedural Terminology, International Classification of Diseases-9th Edition, the Documentation Guidelines and Medicare guidelines; with all payers until a payer inform you that their rules are different than the national rules.  The world of third party would be much simpler if everyone complied with the national rules and guidelines. [ Back to top ]

When billing for OCT is it better to bill RT and LT modifiers or 50 .....

Q. When billing for OCT is it better to bill RT and LT modifiers or 50 when we’re doing it on both eyes at a single visit?

A. It is customary to list 92135 on two separate lines, with the RT and LT modifiers, respectively.  [ Back to top ]

Clarification on documentation for routine exam with refraction

Q. Clarification on documentation for billing S0620 routine exam with refraction

A. S0 620 is defined ‘routine ophthalmological examination, includes refraction, new patient.'  S0 621 is the same code for established patients.   These are HCPCS codes, not CPT, and as a result, most doctors continue to use the 99000 or 92000 visit codes, combined with 92015, refraction, to report their eye care visits.  Most eye doctors are more comfortable using the CPT codes for reporting their visits and therefore the use of the S codes is pretty low.  

The word 'routine' in the definition may be understood to mean that the visit had no medical reason/chief complaint/presenting problem.  Doctors who choose to use the S codes would use them whenever there was no medical reason for the visit, whether the patient has insurance to cover the visit or not.  This is further complicated because most of the vision plans that cover the 'non medical visits' don't accept the use of the S code.  

The only advantage I see in the S codes is that offices can establish fees for their 99000 and 92000 office visits as if they are always used for medical cases, reserving the S codes; in most cases with a lower fee; for the visits without a medical reason. [ Back to top ]