66984: Coordinate With Surgeon To Ensure Proper Payments

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Clue: Take a look at the original coding before you report 366.10 every time.


When more than one physician is involved in a patient's cataract care, see to it that diagnosis and procedure codes match up or you will land a denial. Here are two pointers to help you get your payments for cataract comanagement on time.

Tip 1: Match codes to stay away from denials


The number one reason for cataract co-management denials is the OD reporting a different diagnosis code than the ophthalmologist. According to experts, if the code does match up, one of those physicians is going to be denied.

Here's what to do: Stay away from across-the-board use of 366.10 (Senile cataract, unspecified) and retrieve the precise diagnosis code from the ophthalmologist prior to sending out a claim.


Here's an instance: If the ophthalmologist makes use of 366.13 (Anterior subcapsular polar senile cataract), the optometrist should use 366.13.


Try this: The same applies to matching the surgical CPT code you both ...
... are reporting. While 66984 applies to the majority of cataract patients, once in a while the procedure will be difficult and the surgeon will report 66982.


Good news: Since 66982 has a higher relative value than 66984, the postoperative care also will reimburse the OD at a higher level.


See to it that you append modifier 55 (Postoperative management only) to either 66984 or 66982 to represent the post-op services you have provided accurately.


Good idea: Insert a note on the claim form explaining that any documentation required is available upon request. Many practices have used this technique successfully to stay away from denials.

Tip 2: Gather accurate fees with surgeon's input


Yet another common co-management billing error is turning a blind eye to changes in the surgeon's fee structure. It is important to stay in the loop when the ophthalmologist increases her fees so you can earn the entire 20 percent of the Medicare allowable to which you're entitled for postoperative care.


However: That would only apply if the surgeon was charging less than the Medicare allowable, which is not likely.

Remember: Many a time, the surgeon will provide initial postoperative care prior to transferring the patient to the OD. In this situation, it is important to coordinate on the number of days each physician is providing care and enter those numbers on separate claim forms.


Keep a look out for: Does the surgeon keep each patient the same number of days prior to referring back to you? That may bring the attention from insurers. If the surgeon always sends the patient back to you after the one-week visit, payers may suspect you have a deal with that surgeon.


In order to figure the split, first calculate 20 percent of the overall charge for the service. After this, divide that total by 90, which is the cataract postoperative global period. This provides you the per-day value of the postoperative management service. In the units field, write in the number of days of service your OD provides, which, multiplied by the per-day rate described above, will yield your total charge for the service.


Tip: The OD can suppose care on the day after the patient is last seen by the surgeon.


Find your share: Call the surgeon after you see the patient to find out if she's filing for postoperative care and, if so, how many days she'll report, so you can bill for the balance. This is also a good time to remind that office to include modifier 54 on its claim form – or else you run the risk of the payer denying your co-management claim.


Try this: If the surgeon is not already using a postoperative form that covers all the bases, offer to help design one. A good form could show the surgery date, which eye the surgeon treated (if not both), the surgeon's postoperative care dates, as well as the number of days that represents. What's more, the form could indicate the date the OD assumed care, the initial refraction, and the resultant acuities. E-mail or fax this completed form back to the surgeon to share the record of the patient's continuing care.


For more on this and for other specialty-specific articles to assist your optometry coding, sign up for a medical coding resource guide like Coding Institute.