Paul Cadorette, CPC, CPC-H, CPC-P, COSC, CASCC, director of education for mdStrategies, discusses five steps to make sure surgery centers are maximizing ophthalmology reimbursement.
1. Coders must have experience with eye anatomy. Coding for ophthalmology procedures is particularly difficult because the anatomical area of the eye is complex. Coders who are familiar with procedures like orthopedics or pain management will need extra training to grasp the differences in ophthalmology coding and anatomical terminology.
"There are a lot of problems with recognizing the eye anatomy and assigning CPT codes for those procedures," says Mr. Cadorette. "Most people find this a very difficult area to code, so the coders must be really familiar with the eye."
As with other specialties, coders can receive special training on the eye anatomy and how to use codes for eye surgery. "With eye procedures, there are bundling issues for CMS," says Mr. Cadorette. "There is a big issue here to make sure you are following the right guidelines."
2. AMA vs. CCI edits. Surgery centers should determine when it is necessary to follow National Correct Coding Initiative edits, although some large corporations require all members to follow CCI edits across the board, the edits are more restrictive and bundle together many ophthalmology procedures. When a carrier allows reporting using AMA guidelines it is beneficial for the centers to use these guidelines to avoid leaving reimbursement on the table.
"If you have a commercial contract, you can report for American Medical Association guidelines, and I recommend you report it that way because you will get extra procedures to maximize reimbursement," says Mr. Cadorette. "The larger corporations with ASCs in many states might require eye centers to follow CCI edits, and that could potentially take away from their revenue."
If you don't have to follow CCI edits, discuss this with the corporation. "Tell them you are bundling when you don't have to and see if you can change," says Mr. Cadorette. "This is especially important for ophthalmology because that's where they are losing some of their revenue."
3. Make sure payor contracts cover implants. Particularly for independent eye centers, it's important to negotiate payor contracts that will cover eye devices and implants, even if it means carving out the implants. Before the negotiations, find out how much each procedure costs the center and the price of the device for each procedure.
"If you can get a reimbursement that would cover the cost of your graft, that's great," says Mr. Cadorette. "Otherwise, have a contract that carves out tissue grafts and other items placed in the eye. When you go into negotiations, know your costs for these devices and how much you are using them. If it turns out to be a significant portion of your revenue, you have to make sure you are reimbursed for it."
Consider this information for all procedures, including corneal grafts, amniotic membrane and shunts. "There are all these devices and grafts that can be expensive and you want to recoup that money as well," says Mr. Cadorette. "You can't let the carrier not reimburse for it, so make sure you are covered in your contract."
4. Don't over code retinal procedures. Retinal procedures are difficult to code because coders must understand everything that was done from the operative note and use the correct codes without over coding. Many of the procedure codes for retinal surgery have five to seven types of procedures covered in a single CPT code, so those procedures can't be coded separately.
"Not only do you have to have knowledge of retinal procedures, but you also have to know the different services included in each code," says Mr. Cadorette. "There are several procedures covered under one code so you can only report the one retina code. If you have a retinal repair, it could include a vitrectomy, membrane peel and injection, but all of those are covered in one CPT."
Inexperienced coders will often over code these procedures, which could cost surgery centers later on. "Surgery centers are trying to maximize their reimbursement, but in some cases if you are over coding you could open the center up to carrier refunds and repayment penalties," says Mr. Cadorette.
5. Accurately code diagnoses for medical necessity. Producing clean claims is important for ophthalmology in surgery centers because if something is coded wrong, you'll have to spend the time fixing the problem before resubmitting the claim and time is money that can detract from a center's profit.
One of the trickiest codes is CPT 67113, which is the repair of a complex retinal detachment. You are only able to code 67113 in certain conditions, so make sure the appropriate diagnosis is available and coded for medical necessity.
"Many times, coders see the operative report for retinal detachments or repairs and say it looks extensive, so they assume they can use the 67113, but they don't have the conditions to support using this code," says Mr. Cadorette. "Even with your regular retina codes, you could have five or six different procedures and coders think it is extensive so they use the extensive code without having enough knowledge of the specialized field of ophthalmology."
If coders attach CPT 67113 to a procedure without the right diagnosis for medical necessity, the claim will be denied.
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1. Coders must have experience with eye anatomy. Coding for ophthalmology procedures is particularly difficult because the anatomical area of the eye is complex. Coders who are familiar with procedures like orthopedics or pain management will need extra training to grasp the differences in ophthalmology coding and anatomical terminology.
"There are a lot of problems with recognizing the eye anatomy and assigning CPT codes for those procedures," says Mr. Cadorette. "Most people find this a very difficult area to code, so the coders must be really familiar with the eye."
As with other specialties, coders can receive special training on the eye anatomy and how to use codes for eye surgery. "With eye procedures, there are bundling issues for CMS," says Mr. Cadorette. "There is a big issue here to make sure you are following the right guidelines."
2. AMA vs. CCI edits. Surgery centers should determine when it is necessary to follow National Correct Coding Initiative edits, although some large corporations require all members to follow CCI edits across the board, the edits are more restrictive and bundle together many ophthalmology procedures. When a carrier allows reporting using AMA guidelines it is beneficial for the centers to use these guidelines to avoid leaving reimbursement on the table.
"If you have a commercial contract, you can report for American Medical Association guidelines, and I recommend you report it that way because you will get extra procedures to maximize reimbursement," says Mr. Cadorette. "The larger corporations with ASCs in many states might require eye centers to follow CCI edits, and that could potentially take away from their revenue."
If you don't have to follow CCI edits, discuss this with the corporation. "Tell them you are bundling when you don't have to and see if you can change," says Mr. Cadorette. "This is especially important for ophthalmology because that's where they are losing some of their revenue."
3. Make sure payor contracts cover implants. Particularly for independent eye centers, it's important to negotiate payor contracts that will cover eye devices and implants, even if it means carving out the implants. Before the negotiations, find out how much each procedure costs the center and the price of the device for each procedure.
"If you can get a reimbursement that would cover the cost of your graft, that's great," says Mr. Cadorette. "Otherwise, have a contract that carves out tissue grafts and other items placed in the eye. When you go into negotiations, know your costs for these devices and how much you are using them. If it turns out to be a significant portion of your revenue, you have to make sure you are reimbursed for it."
Consider this information for all procedures, including corneal grafts, amniotic membrane and shunts. "There are all these devices and grafts that can be expensive and you want to recoup that money as well," says Mr. Cadorette. "You can't let the carrier not reimburse for it, so make sure you are covered in your contract."
4. Don't over code retinal procedures. Retinal procedures are difficult to code because coders must understand everything that was done from the operative note and use the correct codes without over coding. Many of the procedure codes for retinal surgery have five to seven types of procedures covered in a single CPT code, so those procedures can't be coded separately.
"Not only do you have to have knowledge of retinal procedures, but you also have to know the different services included in each code," says Mr. Cadorette. "There are several procedures covered under one code so you can only report the one retina code. If you have a retinal repair, it could include a vitrectomy, membrane peel and injection, but all of those are covered in one CPT."
Inexperienced coders will often over code these procedures, which could cost surgery centers later on. "Surgery centers are trying to maximize their reimbursement, but in some cases if you are over coding you could open the center up to carrier refunds and repayment penalties," says Mr. Cadorette.
5. Accurately code diagnoses for medical necessity. Producing clean claims is important for ophthalmology in surgery centers because if something is coded wrong, you'll have to spend the time fixing the problem before resubmitting the claim and time is money that can detract from a center's profit.
One of the trickiest codes is CPT 67113, which is the repair of a complex retinal detachment. You are only able to code 67113 in certain conditions, so make sure the appropriate diagnosis is available and coded for medical necessity.
"Many times, coders see the operative report for retinal detachments or repairs and say it looks extensive, so they assume they can use the 67113, but they don't have the conditions to support using this code," says Mr. Cadorette. "Even with your regular retina codes, you could have five or six different procedures and coders think it is extensive so they use the extensive code without having enough knowledge of the specialized field of ophthalmology."
If coders attach CPT 67113 to a procedure without the right diagnosis for medical necessity, the claim will be denied.
More Articles on Surgery Centers:
5 Succession Planning Tips From Stateline Surgery Center
ICD-10 is Coming: 10 Steps for Full Implementation
7 Tips for Building Great Commercial Payor Relationships