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CPT-2007 Adds Code 92025 For Corneal Topography

Third Party Newsletter

NEBRASKA OPTOMETRIC ASSOCIATION

January 2007

Volume 7 Issue 1

Finally, in the 2007 edition, CPT has included a code for corneal topography: 92025. And Medicare has adopted this code into its fee schedule for 2007. For the Medicare participating provider: ♦ Total reimbursement is $24.89; ♦ The technical component (TC modifier) is $10.25; ♦ The professional component (26 modifier) is $14.64. (As usual, there is no need to break down the fee into separate components in most instances.)

Our Medicare Carrier’s LCD for corneal topography reimbursement is rather specific, and includes only the diagnoses listed in the box below. Topography related to elective refractive surgery is explicitly excepted. The LCD can be found at: HTTP://WWW .NEBRASKAMEDICARE.COM/PART_B/LMRP/ POLICIES/COMPUTERCORNEALTOPOGRAPHY.HTM

Medicare: DIAGNOSIS CODES THAT JUSTIFY CORNEAL TOPOGRAPHY 92025 Computerized Corneal Topography is indicated in the following conditions: Pre- and post- penetrating keratoplasty and post kerato-refractive surgery, irregular astigmatism, and keratoconus. See specific diagnoses below: 367.22 Irregular astigmatism 371.46 Nodular degeneration of cornea (Salzmann's nodular dystrophy) 371.48 Peripheral degenerations of cornea (Marginal degeneration of cornea [Terrien’s]) 371.60 Keratoconus, unspecified 371.61 Keratoconus, stable condition 371.62 Keratoconus, acute hydrops 996.51 Mechanical complications of other specified prosthetic device, implant, and graft; due to corneal graft V42.5 Organ or tissue replaced by transplant; cornea V45.61 Cataract extraction status (this diagnosis must be accompanied by diagnosis code 367.21 or 367.22) V45.69 Other states following surgery of eye and adnexa Inside this issue: YOUR CLEARINGHOUSE MUST FILE MEDICARE CLAIMS ELECTRONICALLY. IF THEY FILE PAPER CLAIMS, THE CLAIMS WILL BE RETURNED.

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MEDICARE CLAIMS FILED WITH INCORRECT PATIENT NUMBERS WILL BE DENIED AND REPORTED BACK ON THE REMITTANCE ADVICE.

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THE MOST COMMON ERRORS ON NORIDIAN CMS-1500 CLAIMS ARE SHOWN, AND CORRECT FILING EXPLAINED.

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MEDICARE B HAS A NEW POWERPOINT PRESENTATION AVAILABLE ON “UNDERSTANDING REMITTANCE ADVICE”.

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PROPOSED MEDICARE PAYMENT CUTS FOR 2007 WERE AVERTED BY LAST MINUTE CONGRESSIONAL ACTION.

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UP TO EIGHT DIAGNOSES WILL BE ALLOWED PER MEDICARE CLAIM STARTING IN JULY.

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IF YOU WERE RECEIVING ELECTRONIC PAYMENT FROM CIGNA, BUT HAVE NOT FILED A CMS 588, NORIDIAN PAYMENT WILL REVERT TO CHECK.

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NORIDIAN, OUR MEDICARE MEDICAL EQUIPMENT CONTRACTOR, MAINTAINS A REFRACTIVE LENS LCD & POLICY ARTICLE VIA CMS.

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YOU CAN NOW RE-OPEN A MEDICARE CLAIM BY TELEPHONE IN ORDER TO CORRECT CLERICAL ERRORS OR OMISSIONS.

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THE LIMITATION ON BILLING MEDICARE FOR

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FAMILY MEMBERS IS EXPLAINED.

NOA AUDIT LITE, REVIEWING 10 MEDICARE RECORDS OF YOUR CHOOSING,

January 2007

WILL BE AVAILABLE IN FEBRUARY.

ARE YOU UNDERCODING?

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Medicare Potpourri Paper Claims from Clearinghouses Returned by Medicare If a clearinghouse submits claims for you on paper (rather than electronically) your payments may be affected. The Administrative Simplification Compliance Act (ASCA) requires that claims a clearinghouse submits to Medicare on your behalf must be submitted electronically. When your carrier identifies that a clearinghouse has submitted a claim for you on paper, they will return the claim unprocessed to the clearinghouse. There is evidence that some clearinghouses are routinely submitting paper claims without the providers’ knowledge. You should be aware that if your carrier determines that a provider’s clearinghouse has submitted claims in paper form, they will return them to the clearinghouse without action.

Claims Filed with Incorrect Patient Medicare Numbers to be Denied and Reported Back on Remittance Advice Notice Effective December 1, 2006, when you file a claim with an incorrect Medicare number, the claim will be denied and returned to you on the remittance advice (RA) notice. These claims can easily be identified on your RA by looking at the Medicare beneficiary number reported back on the RA. It will reflect the last nine digits of the Internal Control Number (ICN) of the claim followed by “CZ” in the HIC field on the RA. Example: If the ICN were 1206012345678, the Medicare number would be reported back to you as 012345678CZ. The patient’s name and account number will be reported on the RA as you submitted them originally. When you receive these denials, please verify the correct Medicare number of the patient and file a new claim. Providers subject to the Administrative Simplification Compliance Act (ASCA) must file an electronic claim. Those providers who meet one of the exception criteria for ASCA may file an electronic or paper claim for processing. PAGE 2

Common CMS-1500 Claim Errors Below are the top four reasons Education Status letters are sent by Noridian to DME suppliers for claim errors. Item 21-Diagnosis: Written Description instead of, or in addition to, diagnosis code. • Enter the patient's diagnosis/condition. Enter the diagnosis code only, not the description. • Enter up to four codes in priority order. Item 24D- HCPCS/Modifer: Written Description instead of, or in addition to, diagnosis code. • Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with the HCPCS code. • Enter the specific procedure code without a narrative description. However, when reporting an "unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in Item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. • Modifiers must be two alpha/numeric characters. Do not place extra narrative after or under the procedure code. Item 24E—Diagnosis Pointer: includes more than one box 21 reference number, or includes data other than a box 21 reference number. • Enter the diagnosis code reference number as shown in Item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per item. When multiple services are performed, enter the primary reference number for each service, either a 1, or a 2, or a 3, or a 4. • If a situation arises where two or more diagnoses are required for a procedure code, the supplier must reference only one of the diagnoses in Item 21. • Place only a single diagnosis pointer on each line. The actual diagnosis should not be placed in this item. Diagnosis narrative should not be placed in this item. Item 33-Supplier Number: in Incorrect Format • Supplier numbers are ten digits as assigned by the National Supplier Clearinghouse. Do not report an NPI or a UPIN in Item 33 or 24K.

January 2007

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Medicare Potpourri Medicare PowerPoint On-line:

Understanding Remittance Advice

Our Medicare Carrier, Wheatlands Administrative Services (the new name for BCBSKS’s Medicare section), has posted a MS PowerPoint presentation to their website entitled “Understand A Remittance Advice”. Dr. Quack reviewed it and found it to be very informative. If you or any of your staff have difficulty deciphering the payment information sent to you by Medicare, we suggest that you take a few minutes to view this PowerPoint. It can be found by going to the following URL Link: http://www.wheatlandsadmin.com/ part_B/workshops/agenda_ask_contractor.htm

CONGRESS OK's AOA-BACKED PLAN TO HALT MEDICARE PAYMENT CUTS FOR 2007 The "Tax Relief and Health Care Act of 2006" was approved by the House on Friday, December 8th and the Senate in the early hours of December 9th immediately before the final post-election "lame duck" session of the 109th Congress came to a close. Included in the bill are provisions that the AOA helped to shape to avert the announced across-theboard cut of 5% in Medicare physician payments resulting from the flawed sustainable growth rate (SGR) formula. At the same time, ODs, ophthalmologists, and other providers may still face some unrelated reductions in Medicare payments next year -- in the 3% to 5% range for optometrists -- due to the budget neutrality adjustments applied to work values and practice expense methodology changes. The bill also calls for the implementation of a quality reporting system for physician services that offers the potential of bonus payments for physicians. HTTP://BY101FD.BAY101.HOTMAIL.MSN.COM/CGI-BIN/GETMSG?MSG=1496D16D-F0C2-4E7F-8B94495B944F987E&START=0&LEN=46879&MSGREAD=1&IMGSAFE=Y&CURMBOX=123C50AF%2D29D0%2D44DE% 2D85BD% 2D5014DB65AE0C&A=1D0ACCEBE3CA3474CD403D1F27307FC3DD32DA317FC13919E910F4321558B451

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Up to Eight Diagnosis Codes to be Allowed per Medicare Claim Currently the Medicare carrier standard claims system uses only the first four diagnosis codes when processing HIPAA format claims. This despite the American National Standards Institute (ANSI) allowing up to eight diagnosis codes in the 2300 loop on electronic claims. Carriers have used a manual process to consider the remaining diagnosis codes when making Medicare payment determination. CMS is requiring, effective no earlier than July 1, 2007, that a Medicare carrier’s standard system capture and process all diagnosis codes that are reported, up to the maximum of eight, on any claim processed, electronic or paper. Dr. Quack does not believe this change in policy will affect optometric claims; and he assumes the additional four diagnoses on paper claims will be reported in box 19, if they are ever needed.

Termination of Electronic Funds Transfer NAS became the Jurisdiction D DME Medicare Administrative Contractor on September 30, 2006. Due to this change in DME Medicare contractors for Jurisdiction D, the Centers for Medicare & Medicaid Services required NAS to obtain new CMS 588 Authorization Agreement for Electronic Funds Transfer forms from suppliers who were receiving payments electronically from the outgoing contractor. If you are receiving EFT and have not already submitted updated paperwork authorizing NAS to continue EFT payments, time ran out as of December 1, 2006! Any supplier who did not submit a properly completed CMS 588 to NAS prior to December 1, 2006 will revert to receiving paper checks. For complete information, see www.noridianmedicare.com/dme/news/docs/2006/november/ eft_termination.html

January 2007

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Noridian (NAS) Local Coverage Determinations (LCDs) for Refractive Lenses Local Coverage Determinations for durable medical equipment are available through CMS' Medicare Coverage Database in a categorized, searchable format. Suppliers are encouraged to subscribe to the PSC electronic mailing list to assure the most current information regarding LCDs and related articles is available. The PSC offers a LCD directory for suppliers to assist in obtaining coverage information. Current LCDs and Articles can be found at HTTP://WWW.EDSSAFEGUARDSERVICES.EDS-GOV.COM/PROVIDERS/DME/LCDCURRENT.ASP

The CMS LCD for Refractive Lenses, including V-codes, can be found at HTTP://WWW.CMS.HHS.GOV/MCD/CPT_LICENSE.ASP?PAGE=SEARCH1.ASP&TYPE=LCD&FROM=BASKET&LMRP_ID=51&LMRP_VERSION=26&VIEWAMA=N&BASKET=LCD%3A51%3A26% 3AREFRACTIVE+LENSES%3ADME+PSC%3AELECTRONIC+DATA+SYSTEMS+CORP%2E+%2877006%29%3A

The CMS refractive lens policy article, which explains coverage and limitations, can be found at HTTP://WWW.CMS.HHS.GOV/MCD/CPT_LICENSE.ASP?PAGE=SEARCH1.ASP&TYPE=ARTICLE&FROM=BASKET&ARTICLE_ID=23900&ARTICLE_VERSION=4&VIEWAMA=N&BASKET=ARTICLE% 3A23900%3A4%3AREFRACTIVE+LENSES+%2D+POLICY+ARTICLE+%2D+EFFECTIVE+JANUARY+2005%3ADME+PSC%3AELECTRONIC+DATA+SYSTEMS+CORP%2E+%2877006%29

Telephone Re-openings of Medicare B Claims The Reopening process allows providers/suppliers to correct clerical errors or omissions without having to request a formal appeal. A reopening can be initiated via the telephone or in writing. All decisions on granting re-openings are at the discretion of the contractor. Re-opening requests must be received within one year from the date claim completed processing. Corrective action to be taken on the claim to be reopened: Add modifier 25 Add modifier 76 Add modifier AT Increase in the number of units billed Any other type of correction must be submitted in writing or you may file a new claim. Remember: If the claim or service line was fully denied, a new claim can be submitted. Requesting a Telephone Reopening To request a telephone reopening dial toll free 877-567-7268. Hours of operation are 8:00 AM to 11:00 AM CT, Monday through Friday. There is a limit of three re-openings per call. When calling to request a reopening, please have the following information available: ♦ Caller’s name and phone number ♦ Provider name and Medicare billing number ♦ Beneficiary’s Medicare Health Insurance Claim (HIC) number ♦ Beneficiary’s last name and first initial ♦ Beneficiary’s date of birth ♦ Date of service ♦ ICN of the claim Medicare Reopening Notification If your reopening is approved, an SPR or ERA will notify you of the payment determination. You will not receive a separate determination letter for fully favorable re-openings or re-openings where the original denial is being upheld. MA 130 (unprocessable) claims cannot be reopened. Claims with message MA 130 on the electronic or standard paper remittance advice (ERA or SPR) are missing information that is needed to process the claim, or the information on the claim is invalid, and they cannot be reopened.

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January 2007

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Dr. Quentin Quack’s Queries and Questionable Quotes ~~~~~~~~~~~~~~~~~~~~~~~~~~ Third Party Questions from NOA Doctors and Staff

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Dr. Quentin Quack

Medicare Instructions on Billing Family Members Dear Dr. Quack,

I need to bug you for some more information. If the doctor sees a family member for a glaucoma issue, can he bill Medicare? I know there are limitations but how far out on the family tree does it go? Thank you in advance for taking the time to answer my question. Dr Quack’s Quote: You can find the information you are looking for in the Medicare Billing Instructions section of our Medicare Carrier's web site. It is located at: HTTP://WWW.KANSASMEDICARE.COM/PART_B/MANUALS/CHIRO/ BILLING_INSTRUCTIONS.PDF

Read down on the instructions until you reach SERVICES PROVIDED TO IMMEDIATE RELATIVES, which

states.... Charges made by physicians and suppliers for services they provide to beneficiaries, who are considered by Medicare as "immediate relatives" or members of their household, are excluded for Medicare payment (Part A and Part B). For purposes of this provision, "immediate relative" is defined as follows: ♦ Husband and wife; ♦ Natural or adoptive parent, child and sibling; ♦ Stepparent, stepchild, stepbrother and stepsister; ♦ Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; ♦ Grandparent and grandchild; and ♦ Spouse of grandparent and grandchild. Let me know if you need more information.

Coming Soon: NOA Medicare Audit Lite...are YOU under-coding? Dear Dr. Quack:

I understand the NOA audit that you perform is quite comprehensive, but does take significant time on the part of office personnel in preparing the 25 Medicare records, doing self-audit procedures, and so forth. We are really pressed for time at our office; is there any way that we can have you audit a few records without investing so much time in preparation? I think we are under-coding and suffering loss of income as a result. Dr. Quack’s Quote:

Yes. You can. Starting February 1st Dr. Quack will begin offering “Medicare Audit Lite”, which will entail auditing 10 Medicare records of your choice. They may include Medicare B claims using

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99000 codes or 92000 codes, or postop glasses claims with DME MAC, or any combination of the three. Cost will be $600. Although this “Lite” audit will require your office staff to prepare information on those 10 records, maximum time invested should only be an hour or two. And, after looking at your results of this Audit, you feel you would like additional records audited, the cost per record will be only $50.

compliance with Medicare requirements. Down-coding, intentional or otherwise, is non-compliant. Correcting erroneous documentation and coding habits can have a significant impact on a provider’s bottom line, and simultaneously bring that provider into compliance with Medicare requirements. Look for more information on Audit Lite in our next 3rd Party Newsletter.

You mentioned under-coding. Dr. Quack has found a significant number of doctors are erroneously undercoding, which Medicare considers as erroneous as over-coding. The purpose of the audit is to make sure you are in January 2007

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NEBRASKA OPTOMETRIC ASSOCIATION 1633 Normandy Court, Suite A,

Lincoln, NE 68512

ABSTRACTS OF THIS MONTH’S ISSUE NEW CODE 92025 FOR CORNEAL TOPOGRAPHY CPT-2007 has included a code for corneal topography: 92025. Medicare has adopted this code into its fee schedule for 2007. Limitations are explained. Pg. 1. PAPER CLAIMS FROM CLEARINGHOUSES DENIED Claims a clearinghouse submits to Medicare on your behalf must be submitted electronically. Paper claims will be returned. Pg. 2. CLAIMS FILED WITH INCORRECT MEDICARE NUMBERS Effective December 1, 2006, when you file a claim with an incorrect Medicare number, the claim will be denied and returned to you on the remittance advice (RA) notice. Pg. 2.

COMMON CMS-1500 CLAIM ERRORS The most common Noridian CMS-1500 claim errors are found in claim items 21, 24D, 24E, and 33. The correct method of completing these items is explained. Pg. 2.

UNDERSTANDING REMITTANCE ADVICE Our Medicare Carrier has posted a PowerPoint presentation to their website entitled “Understand A Remittance Advice”. We suggest that you take a few minutes to view this PowerPoint. Pg. 2.

CONGRESS HALTS MEDICARE PAYMENT CUTS FOR 2007 The "Tax Relief and Health Care Act of 2006" was approved by Congress before adjourning. Included are provisions that avert the announced across-the-board cut of 5% in Medicare physician payPg. 3. ments.

UP TO EIGHT DIAGNOSIS CODES PER MEDICARE CLAIM CMS is requiring, effective no earlier than July 1, 2007, that a Medicare carriers standard system capture and process all diagnosis codes that are reported, up to the maximum of eight, on any claim processed, Pg. 3. electronic or paper.

TERMINATION OF ELECTRONIC FUNDS TRANSFER Any supplier who did not submit a properly completed CMS 588 to NAS prior to December 1, 2006 will revert to receiving paper checks.

LCDS FOR REFRACTIVE LENSES Local Coverage Determinations for durable medical equipment are available through CMS' Medicare Coverage Database in a categorized, searchable format. Pg. 4.

TELEPHONE RE-OPENINGS OF MEDICARE B CLAIMS The Reopening process allows providers/suppliers to correct clerical errors or omissions without having to request a formal appeal. A rePg. 4. opening can be initiated via the telephone or in writing.

MEDICARE INSTRUCTIONS ON BILLING FAMILY MEMBERS Charges made by physicians and suppliers for services they provide to beneficiaries considered by Medicare as "immediate relatives" or members of their household, are excluded for Medicare payment Pg. 5. Immediate relative is defined.

NOA MEDICARE AUDIT LITE...ARE YOU UNDER-CODING? Quack will begin performing “Medicare Audit Lite”, which will entail auditing 10 Medicare records of your choosing. They may include Medicare B claims using 99000 codes or 92000 codes, or post-op glasses claims with DME MAC, or any combination of the three. Cost will be $600. Pg. 5.

Dr. Quentin Quack’s Queries...continued A Spanish teacher was explaining to her class that in Spanish, unlike English, nouns are designated as either masculine or feminine. "House" for instance, is feminine: "la casa." "Pencil," however, is masculine: "el lapiz." A student asked, "What gender is 'computer'?" Instead of giving the answer, the teacher split the class into two groups, male and female, and asked them to decide for themselves whether "computer" should be a masculine or a feminine noun. Each group was asked to give four reasons for its recommendation. The men's group decided that "computer" should definitely be of the feminine gender ("la computadora") because: 1. No one but their creator understands their internal logic. 2. The native language they use to communicate with other computers is in-

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1. In order to do anything with them, you have to turn them on. 2. They have a lot of data but still can't think for themselves. 3. They are supposed to help you solve problems, but half the time, they ARE the problem; and 4. As soon as you commit to one, you realize that if you had waited a little longer, you could have gotten a better model. Guess which the teacher picked…. comprehensible to everyone else. 3. Even the smallest mistakes are stored in long term memory for possible later retrieval; and 4. As soon as you make a commitment to one, you find yourself spending half your paycheck on accessories for it. The women's group, however, concluded that computers should be masculine ("el computador") because:

January 2007

The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed Schneider, O.D., Third Party Consultant. To reach Ed (aka Dr. Quack): > Email (BEST): [email protected] (HIPAA Compliant) > Ed’s mobile phone is 402-310-2367. Voicemail available. > Fax number is 402-464-1214. Call Ed before faxing. To reach the NOA Nebraska Optometric Association 1633 Normandy Court Suite A Lincoln NE 68512 Phone: 402-474-7716 Fax: 402-476-6547

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