Common Ophthalmology Coding Questions: Documentation, Modifiers, Audits & More
Ophthalmology coding can get complicated quickly.
Between diagnostic testing, surgical procedures, modifiers, payer-specific rules, medical necessity requirements, and yearly coding changes, even experienced practices can run into questions.
And sometimes the answer is much simpler than it appears.
A surprising amount of information can be found by going back to the basics: reading the CPT descriptor carefully, reviewing the applicable payer policy, and making sure the documentation clearly supports what was performed.
In this Q&A, Jackie from MEDCO walks through several common ophthalmology coding and compliance questions we receive from practices.
What Are the Best Resources to Use During an Audit?
One of the most important things you can do when preparing for—or responding to—an audit is know where to look for guidance.
For Evaluation and Management services, the American Medical Association's E/M documentation guidelines are an important starting point.
For diagnostic testing and other covered services, Medicare's Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) are often some of the most useful resources available.
These policies can help explain things such as:
When a service is considered medically necessary
Which diagnoses may support the service
Documentation requirements
Who may perform the service
Equipment requirements
Frequency limitations
Other coverage requirements
If an LCD or LCA isn't available for a particular service, you may need to look to a National Coverage Determination (NCD).
For Medicaid patients, review the applicable state Medicaid policies.
And when a commercial insurance carrier is involved, don't stop with Medicare guidance. Review that payer's own policies as well.
Most carriers may follow Medicare guidance closely, but there can be important differences.
Your current CPT, ICD-10-CM, and HCPCS manuals should also remain part of your coding toolkit.
The important lesson is that you don't have to rely on memory.
Go back to the source.
How Many Images Are Required for Fundus Photography?
This is a great example of why reading the actual CPT descriptor matters.
For CPT 92250, the descriptor refers to one or more images obtained using fundus photography.
The number of images taken does not automatically create additional billable services.
One image, two images, or several images may still represent the same reportable service for that date of service.
This is also why automatically adding a bilateral modifier without first understanding the code can create problems.
Before adding a modifier, read the descriptor and any applicable guidance surrounding the code.
Sometimes the answer is already sitting right in front of you.
Can CPT 67808 Be Reported More Than Once When Multiple Chalazia Are Treated?
Another common question involves CPT 67808, which describes excision of a chalazion under general anesthesia and/or requiring hospitalization.
The key language in the descriptor is "single or multiple."
That distinction matters.
Whether one chalazion is treated or multiple chalazia are treated during the service, the code itself already accounts for single or multiple lesions.
This is another situation where understanding a few words inside the CPT descriptor can prevent unnecessary units or modifiers from being added to a claim.
How Can Technicians Improve Documentation for Diagnostic Testing?
Technician documentation can become incredibly important during an audit.
In fact, there are situations where the technician's documentation helps provide the information needed to support the service.
For diagnostic testing such as visual fields, OCTs, and other ophthalmic testing, the documentation should create a clear picture of what happened.
Whenever applicable, consider documenting:
What test was performed
Why the test was ordered
The diagnosis or clinical indication
The date the test was performed
Who performed the test
Relevant technician credentials
Test reliability
Whether the patient understood and cooperated with the testing
Any circumstances that may have affected the quality of the test
The physician's interpretation should also clearly document the findings.
But there is another piece that is sometimes overlooked:
What did the physician do with the information?
A test shouldn't simply exist in the chart.
The documentation should help demonstrate how the results contributed to the patient's assessment, treatment plan, follow-up, or other clinical decision-making.
That connection helps establish why the test was medically necessary in the first place.
And, of course, documentation should be appropriately signed and dated.
What Coding Errors Commonly Lead to Ophthalmology Claim Denials?
Although individual cases vary, many coding problems tend to fall into a few recurring categories.
1. Medical Necessity Isn't Supported
Putting a diagnosis code on a claim is not enough by itself.
The medical record should support the diagnosis, indication, or reason for performing the service.
There should be documentation within the patient's history, examination, findings, or other parts of the record that helps explain why the test or procedure was needed.
2. Practices Don't Keep Up With Revised Codes
Every year, coding professionals tend to pay attention to two things:
What's new?
and
What was deleted?
But revised codes can be just as important.
A code you've used for years may suddenly have different wording or requirements.
A revision could mean additional documentation is needed, a code should be used differently, or a service that previously wasn't applicable may now be reportable.
When annual coding updates are released, review:
New codes
Deleted codes
Revised codes
All three matter.
3. The Wrong Modifier Is Used
Ophthalmology uses a lot of modifiers.
That makes understanding modifier requirements especially important.
Depending on the service, you may need to consider laterality, anatomical location, or whether a service was separate and distinct.
Upper lid versus lower lid.
Right eye versus left eye.
Bilateral versus unilateral.
Those details matter.
And again, before reaching for a modifier automatically, read the CPT descriptor and the applicable payer policy.
4. The Practice Ignores Payer-Specific Policies
This is one of the biggest recurring themes in medical coding:
Know your payer.
Medicare guidance may give you an excellent starting point, but individual insurance carriers can have their own requirements or interpretations.
Those small differences can affect how a service should be documented or reported.
The details matter.
Why Should You Avoid Unspecified ICD-10 Codes When Possible?
Sometimes an unspecified code is appropriate.
But when greater specificity is available and supported by the medical record, use it.
Ophthalmology frequently gives you the ability to identify things such as:
Right eye
Left eye
Bilateral involvement
Specific anatomical locations
Specific stages or types of a condition
That specificity doesn't just improve the claim.
It can also help demonstrate medical necessity and create a clearer clinical record.
Frequent use of unspecified diagnosis codes can also create additional questions during payer reviews.
The goal isn't simply to choose the most detailed code available.
The goal is to choose the most accurate and specific code supported by the documentation.
Make Sure the Diagnosis Is Linked to the Correct CPT Code
Even when the correct diagnosis and procedure codes appear somewhere on the claim, problems can occur if they aren't linked correctly.
On the CMS-1500 claim form, the diagnosis supporting a particular procedure needs to be appropriately connected to that service.
It's a relatively small detail, but it can have a major effect on whether the payer understands the medical necessity of the service being submitted.
How Should Punctal Plug Placement Be Reported?
For punctal plug placement using CPT 68761, laterality and anatomical modifiers become particularly important.
When plugs are placed in multiple puncta, the service may need to be reported on separate claim lines using the appropriate eyelid modifiers, such as E1 through E4, depending on the payer's requirements.
But here's the important part:
Not every payer handles those modifiers the same way.
Medicare may recognize the eyelid-specific E modifiers, while another payer may require a different combination of laterality modifiers.
This is exactly why payer policies should be reviewed before assuming that the same billing method applies to every insurance carrier.
Can You Bill an Office Visit and a Procedure on the Same Day?
This is one of the questions we receive most often.
And this is where modifier 25 comes into the conversation.
Every procedure includes some amount of evaluation associated with performing that procedure.
That work is generally considered part of the procedure's global surgical package.
Because of that, you can't automatically bill a separate E/M service simply because the provider evaluated the patient before performing the procedure.
For a separate E/M service to be reported, the visit generally needs to represent significant, separately identifiable work beyond what is normally associated with the procedure.
That might involve evaluating a separate problem or performing additional medically necessary work that goes beyond the usual pre-procedure evaluation.
If the documentation supports that distinction, the E/M service may be reported with modifier 25.
The important word here is separate.
The medical record should make that clear.
The Biggest Takeaway: Don't Guess
If there is one theme running through all of these questions, it's this:
Don't rely on assumptions when the answer can usually be verified.
Read the code descriptor.
Review the parenthetical instructions.
Check the LCD or LCA.
Look at the payer's policy.
Make sure the diagnosis supports the service.
And make sure the medical record tells the same story as the claim.
A few minutes spent verifying the details before a claim is submitted can prevent significantly more work later when you're dealing with a denial, recoupment, or audit request.
Have an Ophthalmology Coding Question?
We regularly receive questions from ophthalmology practices, technicians, billers, and coding professionals, and we'll continue answering them in future videos.
If you have a coding, documentation, audit, or compliance question you'd like us to discuss, send it to heather@medcoinc.co.
Your question may be featured in an upcoming MEDCO Q&A.