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Part 2Part 2 Filing 3Filing 3rdrd Party Claims Party Claims

Addressing:Addressing:• Services and Procedure CodingServices and Procedure Coding•92000 Ophthalmology Codes92000 Ophthalmology Codes

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DisclaimersDisclaimersThis information was prepared by the 3rd Party

Consultant to the Nebraska Optometric Association, Ed Schneider OD.

To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free.

It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

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DisclaimerDisclaimer• The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services.• The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

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BOTTOM CMS-1500 Service & Materials Supplied

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Coding the Services You Coding the Services You ProvidedProvided

• Must correctly code the level of care Must correctly code the level of care providedprovided

• Practitioner is ultimately responsible for Practitioner is ultimately responsible for correct codingcorrect coding

• Under-codingUnder-coding is as incorrect as over-is as incorrect as over-codingcoding

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ReferenceReferenceCurrent Procedural Terminology, or CPT

Updated annually, so needs to be replaced annually.

Covers

•Examination coding,

•Ancillary testing coding

•Some dispensing and CL coding.

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Examination CodingExamination Coding• Medical Exam Coding:Medical Exam Coding:

• Uses CPT coding…either theUses CPT coding…either the– 92000 Ophthalmology Codes, or 92000 Ophthalmology Codes, or – 99000 Evaluation & Management Codes99000 Evaluation & Management Codes

• Routine Exam Coding:Routine Exam Coding: • Definitions unique to each routine 3rd PartyDefinitions unique to each routine 3rd Party• Follow definitions & directions in Provider Follow definitions & directions in Provider

ManualsManuals

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Medical Examination Medical Examination Coding Coding

92000 Ophthalmology Codes defined in CPT92000 Ophthalmology Codes defined in CPT

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Medical Examination Coding Medical Examination Coding

New Estab

92002 (int) 92012 (int)

92004 (cmp) 92014 (cmp)

92000

Ophthalmology Codes

Intermediate

NEW: It’s been 3 years since any OD in your office has seen the patient.

1010

Medical Examination Coding Medical Examination Coding

New Estab

92002 (int) 92012 (int)

92004 (cmp) 92014 (cmp)

92000

Ophthalmology Codes

Comprehensive

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Medical Examination Medical Examination Coding Coding

92000 Ophthalmology Codes defined in CPT92000 Ophthalmology Codes defined in CPT•Chief Complaint

•History (3 parts)

•Examination

•Initiation or Continuation of Diagnostic and Treatment Services

•Medical Necessity (2 parts)

•Final Outcome Table

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Chief ComplaintChief Complaint A brief explanation of why the patient is in A brief explanation of why the patient is in

the office.the office. The Chief Complaint drives the encounterThe Chief Complaint drives the encounter To bill a medical insurer, the chief To bill a medical insurer, the chief

complaint must demonstrate Medical complaint must demonstrate Medical NecessityNecessity

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Chief ComplaintChief Complaint Examples of Medical Necessity:Examples of Medical Necessity:

– Eye pain Eye pain – Red eyeRed eye– Loss of VisionLoss of Vision– Flashes and FloatersFlashes and Floaters– Evaluation and management ofEvaluation and management of

CataractsCataracts Macular DegenerationMacular Degeneration GlaucomaGlaucoma

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Chief ComplaintChief Complaint Examples of NOT Medically Examples of NOT Medically

NecessaryNecessary– Routine examRoutine exam– CheckupCheckup– No complaint No complaint – Need new glassesNeed new glasses– ““Blurred vision” w/ reading, driving, etc.Blurred vision” w/ reading, driving, etc.

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1616

1717

1818

blepharitis 1 1

cartaract 1 2

glaucoma 41

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92000 Score Sheethttp://nebraska.aoa.org/prebuilt/noa/92000-CPT-Documentation-Score-Sheet-2011.pdf

2020

Final Code must beFinal Code must beReasonable and NecessaryReasonable and Necessary ConsideringConsidering• HistoryHistory• Presenting ProblemPresenting Problem• Clinical findingsClinical findings

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Thank You for ListeningThank You for ListeningWe hope this information has been We hope this information has been

helpful.helpful.Thank you for listening!Thank you for listening!See our NOA Website for more 3See our NOA Website for more 3rdrd Party Party

Educational Videos.Educational Videos.

33rdrd Party Services Party ServicesNebraska Optometric AssociationNebraska Optometric Association