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Issues that will affect Optometry in 2016

February 24, 2016

Issues that will affect Optometry in 2016

As we all know by now that the ICD-10 coding system has brought in many changes in the way we need to code. For specialists especially, there are changes with respect to coding of laterality and the way modifiers can be employed as compared to the previous ICD-09 coding system. Besides the code changes with ICD-10 coding, the Accountable Care Act, or popularly known as Obamacare Act, has also brought in changes in the way healthcare practitioners and specialists will need to perform if they need to be reimbursed. The short-sightedness of those who did not start adopting and adapting the ICD-10 coding, and those whose long-sighted vision helped bring in the changes at an early stage, will no doubt reflect on the Revenue Cycle Management process (RCM). The way coders will code dependent on the documentation can lead to revenue loss. Nevertheless, a few pain points in the coming year of 2016, especially for those practicing Optometry, may affect medical billing causing a hit to revenues.

  • In the backdrop of ICD-10 coding system, some Optometrists are wondering how to code and report patients' vague, generalized complaints — blurry vision, dry eyes, or foreign-body sensation, multiple foreign bodies in the eye — Do each have to be coded separately?
  • If coders haven't been updated about 2016 NCCI edits and neglect to add modifiers -59 or –X, revenues may take a hit indirectly affecting the Revenue Cycle Management (RCM)
  • Often payers may deny unbundled claims. On the other hand, payers may often ignore the modifiers and bundle the claims, if this happens then you could be underpaid either way and lose out. The medical billing department needs to recheck every claim put forth
  • So far, the length of a patient's visit has never been factored in when it came to E & M codes (Evaluation & Management care). But in 2016, two new prolonged service codes that could come into play if counseling or coordination of care is the primary reason for the visit, could play spoiler. Hence a relook at the coding options should be pre-eminent as that can directly impact your practice's revenues. Preparing a simple document that compares one's top payers and their reimbursement rates for E & M versus eye codes should help the coders and billers make better decisions that will increase your revenue. It is always best to check with each payer to confirm what is required based on vision diagnosis or medical diagnosis given that Medicare part B does not cover Eye code and the patient is responsible for the payment.
  • In this year 2016, PQRS reporting via claims or registries plans to consider all practices on level irrespective of their size. Stand alone practitioners and small practices (those with fewer than 10 eligible professionals) will no longer be exempt from value-based-modifier penalties. The penalty for these smaller practices will stay at 2 percent, affecting your RCM.
  • Several ophthalmology codes are scheduled to undergo "misvalued code review" in 2016. Last year had a list of such codes, and there are some new codes included (such as CPT 92002- New Patient Eye Exam). Although not finalized, but inevitable, a review usually leads to a reduction in value. So it's better here to plan for lower reimbursements for the services present on the list.
  • Vocabulary Shift: Coders need to pay special attention to vocabulary employed in documentation.The claims systems will likely reject codes with descriptors containing 'unspecified.' "Unspecified" (which has the seventh character "0") is too vague and hence the claim will be rejected. Documentation of laterality and stage of the eye problem reported, for example in glaucoma, is very essential for coders to get the code right. The only way to discourage coders from opting for a common option in ICD-10 is to be very specific in documentation to avoid denials. Moreover, never add a digit for laterality if one doesn't already exist, which could kick out the claim.

However, one saving grace is, Medicare won't deny claims with incorrect ICD-10 codes until October 1, 2016. So conduct an audit of the codes and the rules and regulations, or employ third-party vendors to handle this chaos


Category : Best Billing and Coding Practices