April 21Webinar: Understanding Medicare Advantage and Eyecare

This 50-minute webinar will be held on Thursday, April 21, at noon central time. It is only $49 and will be recorded so you can watch it anytime.

This Webinar will be specific to ophthalmology and optometry (Eyecare). It will include:

  1. Overview of the Medicare Advantage (Part-C) program
  2. How is it the same as Part-B?
  3. How is it different from Part-B?
  4. Who are the specific vendors?
  5. What is a “carrier-specific” rule?
  6. How can I get paid the first time, every time?
  7. How do I appeal?
  8. Specific Eyecare CPT codes
  9. And of course Your Questions

If you have any questions please be sure to send them to me beforehand: jeff@eyecodingforum.com

Click here to Order.

Maximizing Revenue through Accurate Coding, Billing, Documentation, and Compliance

This Webinar is recorded and if you can watch it anytime, anywhere. If you select just one, this should be it. Note that it does assume a basic knowledge of concepts and guidelines. If you discover you need additional training, select our Beginner Bundle of Webinars (only $125) on our Order Form.

1. Documenting and reporting 920xx codes

2. Documenting and scoring E & M office visits

3. Know how to score MDM.

4. Updating your fee schedule. Understanding RVU’s

5. Understanding medical necessity

6. Medicare Guidelines and Tips

7. Learn how to appeal denied claims.

8. Reporting optimal levels (audit-proofing your clinic)

9. Knowing information not in the CPT manual (e.g., unilateral vs bilateral codes)

10. Work screenings for high-risk drugs

11. Niche markets: psychiatric, neurology, orthopedics, pediatrics

12. How to document the Interpretation and Report for diagnostic tests

13. A little something extra on ICD-10 (Appendix)

Meaningful Use and Coding Compliance

Meaningful Use and Coding Compliance, Thu, Nov 19, 2015, noon central time, fifty-minutes.

This will be a detailed look at meaningful use from an experienced Eyecare auditor and certified coder.

  1. Is Meaningful Use Attestation the same as being compliant?
  2. Does using an EMR ensure your documentation will pass a coding audit?
  3. How do you know?

Have you ever asked the difficult questions?

I have–and the answers will surprise you.

Click on the Order Tab, order a block of four, or with our Site License option receive this Webinar, access to all recorded Webinars (over 40) plus new Webinars for a full twelve months.

2016 CPT, HCPC, ICD-10, Medicare, Medicaid updates for Ophthalmology and Optometry

The fifty-minute Webinar is Thursday, December 10, 2015, and it will save you between 8-15 hours. How valuable is your time? Jeffrey Restuccio, CPC, COC is an Eyecare coding expert with hundreds of hours of experience in coding and billing exclusively for Eyecare. This webinar will review:

  1. CPT code updates
  2. Level III CPT code updates and changes
  3. Why they’ve changed
  4. How to apply the new codes,
  5. What should be documented to support them.
  6. NCCI edits
  7. RVU updates
  8. Modifier changes
  9. Medicare updates
  10. Local Coverage Determination Updates (Medicare)
  11. 2016 OIG Workplan
  12. 2016 ICD-10 Guidelines updates

This Webinar is $49 or buy a block of 4 for $99; it is included with the Site License (all Webinars and ICD-10 updates for a full year) for only $499. All Webinars are recorded so you can watch anytime and as often as you like.

Workers Compensation and ICD-10

While healthcare providers and physicians may be scrambling to get ready for ICD-10, workers’ compensation practitioners are not required to switch to the new codes, according to the Workgroup for Electronic Data Interchange (WEDI), an advisor to the Department of Health and Human Services.

Approximately one-half of the Workers compensation claims systems are ready to switch to ICD-10 on October 1. About one-half, or 26 states will continue to use ICD-9 codes after Oct. 1 2015. Therefore your PM system will have to support switching between ICD-9 and ICD-10. Plus you staff has to be well-trained to avoid any confusion.

[Also: ICD-10 checklist: AHA releases step-by-step preparation guide]

WEDI has released data on worker’s compensation readiness by state. Twenty-one states have adopted ICD-10 billing for physicians, hospital inpatients and outpatients, according to WEDI.

ICD-10 ready: Alabama, California, Florida, Georgia, Hawaii, Idaho, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, South Dakota, Texas and Washington.

Three states have adopted ICD-10 codes for hospital inpatient billing only: Indiana, Maine and South Carolina.

[Also: With ICD-10 about a month away, healthcare providers say ‘bring it on’]

Continue with ICD-9: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Hawaii, Iowa, Kansas, Kentucky, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Wisconsin and Wyoming.

If you hear anything different please email me at ecf@eyecodingforum.com and we will update this post.

Glaucoma Stage Code Definitions: mild, moderate and severe

The stage coding is based on the Eyecare professional’s judgment. There are several different definitions of the stages, which will be summarized below.

Mild Damage — American Optometric Association Definition

  • Optic Nerve – mild concentric narrowing or partial localized narrowing of the neuroretinal rim; disc hemorrhage; cup/disc asymmetry
  • Nerve Fiber Layer – less bright reflex; fine striations to texture; large retinal blood vessels clear; medium retinal blood vessels less blurred; small retinal blood vessels blurred
  • Visual Field – isolated paracentral scotomas; partial arcuate or nasal step; damage limited to one hemifield with fewer than 25% of points involved, mean deviation (MD) less than -6 dB

Mild Damage — American Academy of Ophthalmology Definition

  • Optic nerve changes consistent with glaucoma but NO visual field abnormalities on any visual field test OR abnormalities present only on short-wave-length automated perimetry or frequency doubling perimetry

Mild Damage — CMS Definition

  • One or more of the following in the worst eye
  • Intraocular pressure >22mmHG
  • Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ration > 0.4
  • Focal optic disc notch
  • Optic disc hemorrhage or history of optic disc hemorrhage
  • Nasal step or small paracentral or arcuate scotoma
  • Mild constriction of visual field isopters

Moderate Damage — American Optometric Association Definition

  • Optic Nerve – moderate concentric narrowing of the neuroretinal rim; increase in the area of central disc pallor; a complete localized notch or loss of the neuroretinal rim in one quadrant; undermining of vessels
  • Nerve fiber layer – minimal brightness to reflex; no texture; large, medium, and small retinal blood vessels clear
  • Visual field – partial or full arcuate scotoma in at least on hemifield; damage may involve both hemifields; fixation should not be involved; mean deviation between -6 dB and -12 dB

Moderate Damage — American Academy of Ophthalmology Definition

  • Optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation.

Moderate Damage — CMS Definition

  • One or more of the following in the worst eye
  • Enlarged optic cup with neural rim remaining but sloped or pale, cup/disc ration >0.5 but <0.9
  • Definite focal notch with thinning of the neural rim
  • Definite glaucoma visual field defect (arcuate/paracentral scotoma), nasal step, pencil wedge, constriction of isopters

Severe Damage — American Optometric Association Definition

  • Optic Nerve  – complete absence of the neroretinal rim in at least three quadrants; bayoneting of vessels; markedly increased area of central disc pallor
  • Nerve fiber layer – reflex dark; no texture; large, medium, and small retinal blood vessels clear
  • Visual field – advanced loss in both hemifields; 5-10 degrees central island of vision; mean deviation worse than -12 dB

Severe Damage — American Academy of Ophthalmolgy Definition

  • Optic nerve changes consistent with glaucoma AND glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least on hemifield.

Severe Damage — CMS Definition

  • One of more of the following in the worst eye
  • Severe generalized constriction of isopters
  • Absolute visual defects within 10 degree of fixation
  • Severe generalized reduction of retinal sensitivity
  • Loss of central visual acuity, with temporal island remaining
  • Diffuse enlargement of optic nerve cup, with cup to disc ratio >0.8
  • Wipeout of all or a portion of the neural retinal rim

If both of the patient’s eyes are glaucomatous, always report for the more severe stage of the two eyes. If the two eyes have different types of glaucoma, document each eye with its type and assign a stage code for each eye.

The indeterminate code would be used when you see a patient that you haven’t yet had time to do a visual field on, the patient just can’t perform a visual field test, or it’s so unreliable or uninterruptable that you really are unsure what level or state they are at.

Risk factors for glaucoma with borderline findings

H40.01*: Open angle with borderline finding, low risk (1-2 risk factors) [Code has laterality] (365.01)

H40.02*: Open angle with borderline findings, high risk (3 or more risk factors) [Code has laterality] (365.05)

The list below includes glaucoma risk factors according the Mayo Clinic:

Because chronic forms of glaucoma can destroy vision before any signs or symptoms are apparent, be aware of these factors:

Elevated internal eye pressure (intraocular pressure). If your internal eye pressure (intraocular pressure) is higher than normal, you’re at increased risk of developing glaucoma, though not everyone with elevated intraocular pressure develops the disease.

Age. You’re at a higher risk of glaucoma if you’re older than age 60, particularly if you’re Mexican-American. You may be at higher risk of angle-closure glaucoma if you’re older than age 40. For certain groups such as African-Americans, however, the risk of developing glaucoma is much higher and occurs at a younger age than that of other groups. If you’re African-American, ask your doctor when you should start having regular comprehensive eye exams.

Ethnic background. African-Americans older than age 40 have much higher risk of developing glaucoma than do whites (Caucasians). African-Americans also are more likely to experience permanent blindness as a result of glaucoma. People of Asian descent have an increased risk of developing acute angle-closure glaucoma. People of Japanese descent may be more likely to have normal-tension glaucoma.

Family history of glaucoma. If you have a family history of glaucoma, you have a greater risk of developing it. Glaucoma may have a genetic link, meaning there’s a defect in one or more genes that may cause certain individuals to be more susceptible to the disease. A form of juvenile open-angle glaucoma has been clearly linked to genetic abnormalities.

Medical conditions. Several conditions may increase your risk of developing glaucoma, including diabetes, heart diseases, high blood pressure and hypothyroidism.

Other eye conditions. Severe eye injuries can cause increased eye pressure. Other eye conditions that could cause increased risk of glaucoma include eye tumors, retinal detachment, eye inflammation and lens dislocation. Certain types of eye surgery also may trigger glaucoma. Also, being nearsighted or farsighted may increase your risk of developing glaucoma.

Long-term corticosteroid use. Using corticosteroid medications, especially eyedrops for a long period of time may increase your risk of developing secondary glaucoma.


Quick LCD list with ICD-10 Codes

WPS Medicare now offers their LCD’s with either ICD-9 or ICD-10 codes. You can compare and contrast both lists. Click here for a complete list.





ICD-10 Updates and Clarifications July 2015

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

JPR: The information below is from the Medicare document above.

As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. However, they are subject to specific LCD or NCD requirements.

JPR: I can think of few unspecified eye codes: ARMD, ectropion, scleritis, or amblyopia that would cause a denial. Most LCD’s for Eyecare include ranges of codes and do not exclude the “unspecified code.” As a certified coder, I am taught that the most specific codes and the group of codes that most accurately reflect the encounter, based on coding guidelines is the proper way to report the service.

For one, unspecific codes inform the world that the provider “does not know what is wrong with the patient.” Both the clinic manager and the provider should want to avoid this impression. While most won’t be able to be in the top ten-percent of clinics in terms of coding accuracy–you don’t want to be in the bottom 50% and certainly not the bottom 10-percent. Being specific, accurate, and following all coding guidelines is the best strategy to get paid, every time, and in all situations, by all carriers. Lastly, if the providers ever wanted to practice medicine because they wanted to help people, here is their opportunity. We need the specificity and additional status codes for research. Universities  worldwide are waiting on more specific data to help prevent and cure diseases. As I stated earlier, improve your diagnosis reporting because it’s the right thing to do.

In another example, a patient has a diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus). Use of the valid codes G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus) instead of the correct code, G43.711, would not be cause for an audit under the audit flexibilities occurring for 12 months after ICD-10 implementation, since they are all in the same family of codes.

JPR: Most in Eyecare use the unspecific headache codes. I recommend, in my ICD-10 training that the provider report the headache more specifically as tension, migraine, ocular, retinal, etc…There is no way for the carrier to know which type of migraine the patient has and the auditor would actually have to review the notes and compare them to the specific code reported. Not all auditors do this so this would be a rare phenomenon.

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4: Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Question 5: What is meant by a family of codes? (Revised 7/31/15)

Answer 5: “Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.

One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

The three official CMS documents are available to download below:




Update to explanation for initial versus a subsequent encounter

This is an update and correction concerning the explanation for initial versus the subsequent office visit encounter (follow-up) for any injury.

In both the live and recorded course I used the new patient and existing patient guidelines to determine whether the visit was initial (XA) or subsequent (XD). While there are some grey areas in the official explanation I am revising my opinion on this matter based on additional information and feedback. The bold and italics below are mine.

This is per the AHA ICD-10 Coding Guidelines Manual Nov 2014 (Chapter 19: pgs 66-67) (full document link at the end of this article):

7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

It could be argued whether the list above means “and” or “or.” Is the new physician a requirement or does the active treatment by any new physician determine it’s initial?

7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition.

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

Additional Notes are from the article below:

Per Guest Contributor, Debra Mitchell, MSPH, CPC-H, In Coding Edge April 1, 2014,  “Take the patient’s perspective when appending the seventh character in ICD-10-CM.”

The statement “evaluation and treatment by a new physician” can be a source of confusion, but you will code correctly if you are able to answer the basic question, “Has the patient previously received active treatment for this condition in any setting or by any provider?”

Per this article, her take is that if the patient saw another doctor in Florida or in the ER for a foreign body in their eye and are now seeing you as a follow-up , then it would be coded as subsequent, not initial based on new versus established patient guidelines.  This is different from my 2014/2015 ICD-10 classes and the recorded training. Based on this new information, I am revising my opinion on this pending any confirmation by Medicare or other official sources (AHA, AHIMA).

I was not able to get any additional confirmation or determine if other information was used to determine this interpretation.

However, per the article, if the patient did not receive active treatment (e.g., remove the foreign body) then this encounter would be the initial, not subsequent. So there is some grey area here. The key is to be consistent in your interpretation among doctors and staff.

The rest of the article explains active treatment:

For example: The patient is evaluated in the emergency room (ER) for a displaced transverse fracture of the left ulna that cannot be managed at this time. The ER applies immobilization and ice and instructs the patient to follow up with orthopedics in the morning. This would be reported using S52.222A Displaced transverse fracture of the left ulna, initial encounter for closed fracture.

When the orthopedist rechecks the patient and reduces the fracture the next day, the patient is receiving initial active treatment for this fracture. That is, this is the first encounter at which the patient receives definitive care (the ER was able to apply comfort care only). Per ICD-10 guidelines, you would again report S52.222A for an initial encounter.

Usage of XA or XD hinges on interpretations of “active treatment” and “definitive” care. If the ER doctor removed two FB from the patient’s eye  but on the subsequent visit to the OD, another FB particle is found and removed, is that an initial or subsequent visit? Based on the interpretation above, I would now code it as subsequent–the patient did receive a foreign body removal service. Think of subsequent as “aftercare” regardless of whether you continue with the treatment or simply monitor it.

For those who know me, I always defer to official sources and I  confirm whether what I am stating is based on my professional opinion or a specific source. Sometimes there is very little official documentation to follow.

I will continue to monitor the definitions and usage of “initial” versus “subsequent” and send my findings to all the EyeCodingForum ICD-10 clients. I will post findings to my website as well. The complete guidelines are below:


Jeffrey Restuccio, CPC, CPC