How to Avoid Common Ophthalmic Billing Rejections: Part 1

OCT/GDX and Fundus Photography

Working with eye care providers across the country, our billers at Fast Pay see many common rejections that could have easily been avoided. In this “Common Billing Rejections” series, we will explore some of the top rejection reasons, starting with the OCT/GDX and fundus photography combination.

Review Medicare and insurance company policies

Keep in mind to always check with your Medicare carrier’s or other insurance company’s policies for up-to-date coding rules—they can change as frequently as every quarter. Additionally, Medicare’s National Correct Coding Initiative (NCCI) edit tables can be found on the CMS website.

Code correctly so you get paid

Many offices bill an OCT/GDX (CPT codes 92133/92134) and fundus photography (CPT code 92250) on the same visit. If you do not code this correctly, Medicare may deny both codes or only allow payment on the code with the lowest reimbursement. If you are looking at a single problem, such as glaucoma, both tests cannot be paid per Medicare’s NCCI edits; codes 92133/92134 and 92250 are considered mutually exclusive.

Use modifier 59 correctly to avoid audits and fines

Modifier 59 defines a “Distinct Procedure Service” and identifies procedures or services that are not normally reported together. However, modifier 59 is one of the most used modifiers and also one that is often used incorrectly. Tip: Never attach modifier 59 to an E&M service.

For example, some offices attempt to use modifier 59 in order to get paid for both OCT/GDX and fundus photography, but many practices frequently use the modifier improperly, which can lead to a Medicare audit and possible fines. Though the NCCI edits do allow the use of modifier 59, determining if it is appropriate under the circumstances can be tricky.

Depending on the local policy, if the tests are necessary due to two separately identifiable conditions, you may be able to link the appropriate diagnosis code to each CPT and add modifier 59 to the second procedure. It is important to keep up with Local Coverage Determinations (LCD) for your area to ensure you are coding claims correctly.

About Fast Pay: At Fast Pay, our billers take care of the billing hassle to maintain consistent cash flow and improve the turn-around time on your claims. We work with each of our offices to provide a solid billing solution. No two practices are alike and we pride ourselves on maintaining open communication between every office and their Fast Pay biller to stay in sync. Contact us for a free practice analysis to see how we can help you.