One of the biggest no-no’s is coding in a pattern and by diagnosis. That is, every patient who has the same diagnosis gets coded in exactly the same way.
Rather, each patient needs to be approached as an individual, with a unique personal and family history, unique clinical findings and the need for unique medical decision-making for the individual’s specific case. Therefore, each patient will also have a unique and individual medical necessity established in the record for any special ophthalmic testing to be done. Likewise, the frequency of the office visits and the special ophthalmic testing are decisions you make on an individual basis for each patient.
Understanding your state- or region-specific payer guidelines associated with the appropriate CPT procedure codes is the only way to understand the complexities of managing your glaucoma patient properly. Let’s start by looking at the diagnostic tests and the accompanying codes typically associated with glaucoma.
Your office visits can be coded using the 920XX codes and the 992XX codes. But remember that the office visit code that you use must be based upon the individual patient and the actual medically-necessary testing that you performed and recorded in the medical record. Don’t assume that because your diagnosis is related to glaucoma that your office visit is automatically elevated to a higher code.
Codes for typical special ophthalmic procedures include:
• 92020 – Gonioscopy
• 92083 – Visual field, threshold
• 92132 – Scanning computerized ophthalmic imaging, anterior segment
• 92133 – Scanning computerized ophthalmic imaging, posterior segment, optic nerve
• 92250 – Fundus photography
• 76514 – Pachymetry
The frequency of these procedures is determined by both the medical necessity and the local coverage determinations established within your specific contracted carrier policies and your evaluation of the patients’ specific presentation. It is becoming more common that carriers are classifying glaucoma into mild, moderate and advanced stages, each with their own specific clinical protocol for frequency of tests (primarily in regard to OCT and visual fields).
(Special note: In last month’s column regarding performing OCT and fundus photography on the same date of service, please keep in mind that a diagnosis of glaucoma was not included in the eligible disease states to allow the use of modifier -59.)
In January 2012, changes were made in the ICD-9 coding system that now allow us to also specify the severity of the disease. This is consistent with the migration to the ICD-10 system coming in October 2014. So if there is a confirmed diagnosis of glaucoma, a second diagnosis should also be included to indicate the stage of glaucoma.
Enter one of the following as a secondary diagnosis to indicate the stage of the disease:
• 365.70 – New; Glaucoma stage unspecified
• 365.71 – New; Mild stage glaucoma
• 365.72 – New; Moderate stage glaucoma
• 365.73 – New; Severe stage glaucoma
• 365.74 – New; Indeterminate stage glaucoma
For example, here’s how moderate stage primary open-angle glaucoma is coded in the ICD-9 system:
• Primary diagnosis – 365.11 (primary open angle glaucoma)
• Secondary diagnosis – 365.72 (moderate stage glaucoma)
In the ICD-10 system, this diagnosis will be indicated in a single code:
• H40.11X2 – Primary open angle glaucoma, moderate stage
Providing glaucoma care is a growing segment in optometry. Be mindful of always diagnosing, treating and coding for the individual patient, and not simply by the diagnosis. By doing so, you will have the upper hand in determining the medical necessity for performing both office visits and ordering any special ophthalmic tests. Ultimately, every patient decision must be based on your determination of medical necessity, not on how you get paid.