Chapter 50 There is a universal need to document a physician’s service provided to a patient. Such a need is obvious in fee-for-service settings, but is also often a requirement to capture each physician’s work in capitated or group practice settings. In the United States Current Procedural Terminology (CPT) (CPT codes and descriptors are copyright 2004, American Medical Association, Chicago, Illinois) is the method used in the outpatient setting.1 This system is a collaborative effort of medical specialty societies and the American Medical Association (AMA). These codes are used to submit a claim for reimbursement to a payer, as well as to collect information about the quantity of work a member of a physician group is providing. Nearly all CPT codes have had relative values assigned by the Center for Medicare/Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). These relative values incorporate physician work, practice expense, and malpractice components. They constitute the basis of payments for professional services under Part B of the Medicare program. The actual payment is determined annually by multiplying the relative value by the conversion factor. A preliminary value is published in August of the preceding year and finalized in November. All physicians must be aware of the specifics of the CPT codes they use. They are ultimately responsible for compliance with all published information about the codes. Such information may include information from CPT at the AMA, but also interpretations from third-party payers, including the federal programs Medicare and Medicaid. These are summarized in periodic mailings (e.g., Part B News) and on the intermediary’s Web site. Many of the rules that are first implemented by Medicare are later adopted by other payers. There are many coding consultants who advise physicians about the use of these codes. Many do a very good job, but some have suggested billing practices that were later determined by the Office of the Inspector General to be overly aggressive and later proven in court to be fraudulent. Critically evaluate the recommendations made and possibly seek another evaluation if a suggestion looks too good to be true. Coverage policy has become an important process in physician reimbursement, and physicians only of late have become concerned. In the past nearly any medical service provided to a patient and submitted to a carrier would be paid. With increased efforts to control spending, limits on covered procedures by nearly every carrier have become more common. For example, it is common to find a patient limited to one automated visual field a year. Such an administrative decision might have been instituted to control the frequency of visual fields for patients with stable open-angle glaucoma. However, such a limitation could be a problem for a patient with visual loss related to a pituitary adenoma. To respond to perceived coverage problems, national policies are mediated by national specialty societies with coverage experts at CMS. For local issues, each of the Medicare intermediaries has a Carrier Advisory Committee composed of physicians from their locality who review payment policies. Such a committee becomes the advocate for both the patient and physician in ensuring coverage of medically necessary and efficacious services. For other third-party payers, the individual medical directors must be approached and a succinct case presented for a particular service. There is little that national specialty medical societies have been able to do in this area, except to provide information about what has worked in other regions of the country. The payment policies and reporting regulations are not constant, but are always changing. A close eye on payment reports and Explanation of Benefits forms may alert you to a change in payment policy. Changes do not always arrive with an announcement from the payer, particularly when it results in a reduction in payment or covered services. Some of these changes may be planned, but others may be inadvertent or erroneous due to a systems upgrade. In both cases a query to the payer may lead to a restoration of previous policy and in many instances some retroactive payment to the practice. • Must be dated and authenticated for billing purposes • Only the services documented will support the claim. • Prevents malpractice cases • Protects against fraud and abuse charges There are annual updates to the printed lists of CPT and the International Classification of Diseases ninth clinical modification (ICD-9-CM). Physicians are responsible for monitoring these and updating billing procedures in their offices. Purchasing the new editions is the best way of detecting the changes, deletions, and additions. The bulk of services are provided on an outpatient basis, though some services may be provided in the hospital or even in a skilled nursing facility. Specific code families are used for documentation when a service is provided in each of these areas. Consult a current edition of CPT for the correct code sequence. The majority of neuro-ophthalmologic services are for evaluation and management (E/M), though several ancillary procedures may also be provided. The most important decision is the category of the service: consultation, new visit, or established visit. The physician must determine whether the service met the definition of consultation and the service provided met the requirements. • A consultation may be requested by another physician or appropriate source, but not the patient or family. It may come from within the same group, as long as that physician does not have the same expertise. • There must be evidence of the request in the consultant’s record. This may be in the form of a written note from the source, documentation of a phone request, or more frequently, a note in the medical record of the request for a consultation. Ideally office staff can help obtain this on initial patient contact. • A written report from the consultant must be sent back to the requesting source. Prior to 1999 the differentiation of a referral from a consultation was vague. Many coders felt a consultation was not performed, whenever a patient was sent to another physician who was to manage a problem. For instance, a comprehensive ophthalmologist saw a 22-year-old woman with painful unilateral visual loss and a swollen disc, diagnosed optic neuritis, and sent the patient to the neuro-ophthalmologist for workup and supervision of any treatment. At that time this might have been termed a referral. In 1999 the HCFA issued new rules that made it clear that if the criteria noted above are met, the service is a consultation and not a referral. The choice of a level of service is complex and depends on the description in CPT and the Documentation Guidelines suggested by CMS (see below). A consultation is reimbursed at a higher rate to account for the increased sophistication of the service and for the added reporting requirements. Follow-up inpatient consultations (99261–99262), which are used to finish the initial consultation or for a subsequent requested visit during the same admission, were deleted in 2005. Most inpatient follow-up care should be reported with subsequent hospital care codes (99231–99233). The exception is when a repeat consultation request is received.
BILLING FOR NEURO-OPHTHALMOLOGIC DISEASES
RULES
COVERAGE POLICY
MONITORING
DOCUMENTATION
CODES
CHOOSING THE CORRECT CODE
Where Is the Service Provided?
What Type of Service?
Consultations
Outpatient Consultations (99241–99245) or Inpatient Consultations (99251–99255)
New/Established
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