In the News

MEDICARE FEE FIX

Congress voted to override President Bush’s veto of H.R. 6331 which includes a fix to the proposed 10.6 percent cut that was scheduled to take place July 1, 2008. The bill extends the January 2008 rates through December 31, 2008 and provides for an additional 1.1 percent fee schedule update in 2009.

Medicare claims will now be released for payment. According to CMS, however, it could take up to 10 days to implement the new fee schedule and some claims will be paid at the reduced fee. Claims paid at the lower rate will require the carrier to make an adjustment with automatic re-processing.

ADVANCED BENEFICIARY NOTICE

On March 3, 2008, CMS implemented a revised Advance Beneficiary Notice (ABN). This form will replace the existing ABN (CMS-R-131G) and the laboratory ABN. Providers will have until September 1, 2008, to start using the new ABN.

In the past, an ABN was only used for services that might be considered “not medically necessary.” The revised version of the ABN may now be used to provide notification of financial liability for services that are excluded from Medicare coverage. CMS believes the new version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB). Since CMS did not specifically state that the NEMB was being discontinued, you might want to consider continuing to use the NEMB for premium IOL services. We believe the NEMB rather than the ABN would be less confusing for the patient in these cases.

ABNs can be customized somewhat to include clinic name and additional information about the service rendered. The ABN can only be reproduced on a single page, and the page may be either letter or legal size. Entries in the blanks must be typed or hand-written but large enough (e.g., 12-point font or 10-point font for detailed information) to allow ease in reading. If the patient’s signature cannot be read, there must also be a printed annotation of the signature.

All providers and supplies must be using the new ABN no later than September 1, 2008. Detailed instructions and the new ABN form can be downloaded from the CMS Beneficiary Notice Initiative web page at www.cms.hhs.gov/bni.

ASC PAYMENT RATE CHANGES

The first phase of the ASC payment rule was implemented in 2007 in which ASC covered procedures were paid at the 2007 ASC facility fee payment or the Hospital Outpatient Department (HOPD) rate, whichever was lowest. Only six ophthalmology codes were affected in 2007, including YAG laser capsulotomy.

Beginning in 2008, CMS implemented a 4-year transition period in which ASCs will be paid at 65% of the HOPD rate based on a blend of the calendar year 2007 ASC payments rates and the revised ASC payment rates. The blended payment will be 75/25 in 2008, 50/50 in 2009, and 25/75 in 2010, with payment being made at the full 65% transition rate in 2011.

The ASC payment for office based procedures (e.g., PRPs, Focal lasers, ALTs, etc.) was capped using the lesser of the physician fee schedule non-facility practice expense amount or the ASC rate developed under the revised ASC payment system. According to CMS, this was to prevent those office based procedures that have been traditionally performed in the office from migrating to the ASC. When these procedures are performed in an ASC in 2008, the physician will be paid at the lower “facility” physician fee schedule amount. In the past, because the procedures were not on the list of ASC covered procedures, the physician was paid at the higher “non-facility” fee amount when the procedures were performed in an ASC.

In 2008, the only ASC supply that will be paid is the acquisition of the cornea tissue, code V2785. All other supplies (e.g., aqueous shunts, scleral tissue, tutoplast, pericardial tissue, etc.) will be included in the ASC facility fee payment.

CMS also indicated that the -SG modifier will no longer be needed in 2008 for ASC facility fee claims. Payment will be made based on the NPI number and the place of service.

In addition, bilateral procedures will need to be reported as a single unit on two separate lines (LT/RT) or with “2” in the units field on one line in order for both procedures to be paid. While the use of the -50 modifier is not prohibited specifically, the modifier will not be recognized for payment purposes and may result in incorrect payment to the ASC. Physicians should continue to use the -50 modifier for their surgical claims.

2008 OIG WORK PLAN

The 2008 Office of Inspector General (OIG) Work Plan highlights issues the OIG feels are worth attention in the coming year. Some of the issues affecting ophthalmology in 2008 are:

Place of Service Errors. OIG to determine if correct place of service is properly billed when performed in an ASC or outpatient department of hospital.
Evaluation and Management Services During Global Fee Period. OIG looking to see if separate payments were made for office visits during the global fee period of surgery and if the number of office visits provided has changed.
Medicare Payments for Selected Physicians. OIG reviewing the appropriateness of Medicare Part B payments for selected physician services including surgery, consultations, home, office and institutional calls. OIG wants to make sure these services were documented and performed in accordance with Medicare requirements.
Incident To Services. The OIG will again review “incident to” services provided by allied health personnel to make sure medical necessity, quality of care, and proper documentation is being maintained.
Assignment Rules by Medicare Providers. The OIG will review whether Medicare providers are adhering to assignment rules in billing Medicare beneficiaries.
Physician Reassignment of Benefits. The OIG will review the extent to which Medicare physicians reassign their benefits to other entities.

More details on these OIG issues and ways to avoid scrutiny can be found in our newsletter, The Messenger, Volume 1, Issue1, 2008.

NEW TECHNOLOGY IOL's

Currently the only NTIOLs that can be billed by the ASC in addition to the ASC facility fee are the following reduced spherical aberration IOLs:

AMO Tecnis (Z9000, Z9001, ZA9003)
Alcon Acrysof IQ (SN60WF)
AMO Tecnis (Z9002)
Bausch & Lomb Sofport AOV (LI61AO, LI61AOV)
AMO Tecnis (AR40xEM)
Alcon Acrysof/Acrysert Delivery system (SN60WS)
AMO Tecnis (ZCB00)
STAAR Affinity Collamer (CQ2015A)

The above lenses will retain NTIOL status through February 26, 2011. When inserted with conventional cataract surgery, the ASC can bill code Q1003 in addition to the cataract procedure and be paid an additional $50. Code Q1003 is subject to coinsurance and deductible.

Implanting an NTIOL, in itself, does not justify the billing of a complex cataract procedure, code 66982.

CONSULTATIONS

In order to bill a consultation, the referring doctor must be asking for the opinion or advice of the consultant on the treatment of his/her patient for a particular condition. When the optometrist or non-surgical ophthalmologist merely sends the patient for cataract surgery, an opinion is not sought, and this would be considered a transfer of care. These visits should be billed as new or established patient visits, not consultations.

However, when the referring doctor requests an opinion as to whether or not the patient is a candidate for surgery, and the patient’s total ocular health and general well being is evaluated, this would, in our opinion, be considered a consultation, not a transfer of care. A letter (or report of recommendations) must be sent back to the referring doctor addressing the request for the consultation and any other issues of concern. This would be true whether or not the consultant determined surgery was needed at that time, or the patient was returned for follow-up until such time as surgery is indicated.

Don’t forget that the request to furnish an opinion or advice must be documented in the Subjective entry of the patient chart. This can be in the form of a phone call from the referring doctor, a written request, or the patient can be the source delivering the request for the consultation. If the patient is the source, then we recommend calling the referring doctor’s office to confirm the request and documenting that phone call in the Subjective entry as well.

See Volume 1, Issue 3, 2008, of our newsletter The Messenger, for additional information on consultations and a consultation case scenario.

PREMIUM IOLs

Physicians may now bill the patient using code V2787 for the additional work involved in implanting astigmatism-correcting intraocular lenses (IOLs) performed in conjunction with conventional cataract surgery. When implanting presbyopia-correcting IOLs, use code V2788. Bill Medicare for the conventional cataract surgery as usual and bill the patient for the extra work and time involved in implanting the premium IOLs.

The ambulatory surgery center or hospital may bill the patient for the extra work involved and/or the cost differential in these premium lenses and the $150 already included in the facility fee for a conventional IOL. Medicare is billed for the conventional cataract surgery which includes payment for the conventional IOL. Bill the patient code V2787 or V2788 as above.

Remember, you are not required to bill Medicare for these excluded services unless the patient asks you to do so for a secondary payer denial.

MOIDIFIER - 25

The Centers for Medicare and Medicaid Services (CMS) issued a program transmittal clarifying the use of CPT modifier -25 to identify a significant, separately identifiable evaluation and management (E&M) service. The Change Request revises the Medicare Claims Processing Manual in response to a recommendation by the Office of Inspector General’s study on the use of the -25 modifier. The study found that monies were improperly paid for claims submitted with this modifier. The majority of the errors were for inadequate supporting documentation.

As a reminder, the -25 modifier is only appended to the office visit when the medical record supports the billing of a “significant, separately identifiable” evaluation by the physician on the same day as a minor surgery. As long as the chart documents an examination above and beyond the usual pre- and post-operative work of the minor surgery, you will be able to bill separately for the office visit. Of course, the “above and beyond” must be medically appropriate and necessary to begin with.

MEETINGS & LECTURES

National Medical Association (NMA) Ophthalmology Practice Management Section, July 30, 2008, Atlanta, Georgia. Speaker: E. Ann Rose
Alcon Ophthalmic Symposium/ASOA Administrators Section, August 23, 2008, San Antonio, Texas. Speaker: E. Ann Rose
JCAHPO Annual Continuing Education Program for Ophthalmic Medical Personnel, November 7-11, 2008, Atlanta, Georgia. Speaker: E. Ann Rose
Caribbean Eye Meeting (ACES/SEE), February 6-10, 2009, Montego Bay, Jamaica. Speaker: E. Ann Rose
Jules Stein Eye Institute & ASCRS Joint Symposium, February 5-8, 2009, Los Angeles, California. Speaker: Heather B. Freeland
ASOA Web Seminar/2009 Coding Update, January, 2009. Speaker: E. Ann Rose
ASCRS-ASOA Symposium & Congress, April 3-8. 2009, San Francisco, California. Speaker: E. Ann Rose
ASCRS-ASOA Symposium & Congress, April 3-8. 2009, San Francisco, California. Speaker: Heather B. Freeland

Please contact us or call (800) 720-9667 for additional information regarding the above lectures and meetings.