With this column, we hope to guide practitioners through the complicated maze of CPT coding. But, how do these codes come into existence? Who decides what new technology is good enough to warrant a new CPT code that will be recognized by medical insurance carriers?

The American Medical Association has a Web page that explains the process leading to a new CPT code (www.ama-assn.org/ama/pub/category/3882.html). Yet, this seemingly organized, rational system becomes a confusing tangle for companies trying to bring their new technology to market. Ophthalmic equipment manufacturers are all too aware of the frustrating, non-linear path that leads to an accepted CPT code.

First of all, there is no federal agency or office assigned to the investigation of new medical technologys usage by Medicare carriers. The FDA may grant 510K approval to a device, but this doesnt even come close to achieving reimbursable status. After spending huge amounts of time and money to research and develop instrumentation, individual equipment companies must now embark on a multi-year quest to educate decision makers about the benefits that the new technology will bring to patients. Often, this requires hiring lobbyists to descend on Capitol Hill to navigate the labyrinth of the legislative process.

Optometry has no direct representation in this process. Currently, all of eye care is represented by a single ophthalmologist who votes on the acceptance of these new codes at the Centers for Medicare & Medicaid Services (CMS).

Think back to the evolution of the corneal topographer, more than a decade ago. The official CPT code for this technology (92025) was not published until 2007. Even now, some carriers routinely deny this procedure as a non-covered service. This is because each local Medicare carrier must independently choose whether to reimburse for a special testing code. Equipment manufacturers must deal with more than 35 individual medical directors at the local level. Each of these generally has an ophthalmologist consultant who helps determine the medical necessity of the new technology. Local Coverage Determinations (LCDs) are developed by the individual carriers, while National Coverage Determinations (NCDs) are the policies adopted by CMS for nationwide coverage.

Even if a procedure is covered by CMS, large carriers, such as Blue Cross or Aetna, often make their own decisions concerning reimbursement that may or may not agree with CMSs decision.

So, how does this basic understanding of the coding process apply to the practicing O.D.? Here are some tips to keep your medical billing program running smoothly:

1. Appreciate that ophthalmic equipment manufacturers accept this risk every time they commit to bringing new technology to market.

2. Continue to provide the best patient care possible, regardless of reimbursement issues.

3. Set your own fees for procedures that are not yet established with the medical carriers. Keep them consistent for all patients.

4. Have patients sign an Advance Beneficiary Notice (ABN) for any test that you know wont be reimbursed by their medical insurance plan due to the limitations of the plan (not for statutorily excluded procedures, such as refraction).

5. Dont code a new technology with an inappropriate established code in order to get paid by the insurance carrier. Sales reps, while helpful, are not coding experts. All practitioners should research the rules on their own; there are many resources to do so.

New technology means new rules and regulations. Many expect rules and reimbursements to tighten for all medical procedures. Embrace new technology, as it allows us to provide better and more thorough care for our patients. But, keep in mind that as new technology evolves, so will our challenges in properly coding for it.

 Clinical Coding Committee

John Rumpakis, O.D., M.B.A., Clinical Coding Editor

D.C. Dean, O.D.

David Mills, O.D., M.B.A.

Laurie Sorrenson, O.D.
Rebecca Wartman, O.D.

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Vol. No: 145:08Issue: 8/15/2008