basics of medical versus z vision coding cpt and …texas.aoa.org/documents/tx/2011...

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Basics of Medical versus Basics of Medical versus Vision CodingVision Coding

Marcus Gonzales, ODMarcus Gonzales, ODTOA Convention 2011TOA Convention 2011

DISCLAIMERDISCLAIMER

This lecture and the concepts within apply to This lecture and the concepts within apply to CPT and Medicare/Medicaid guidelines that are CPT and Medicare/Medicaid guidelines that are currently applicable, but are susceptible to currently applicable, but are susceptible to change over time.change over time.The examples in no way mandate a manner in The examples in no way mandate a manner in which you should practice medicine nor is it the which you should practice medicine nor is it the only way in which one could bill for it. That is an only way in which one could bill for it. That is an individual physicianindividual physician’’s decision.s decision.Any fees presented in these examples in no Any fees presented in these examples in no manner mandate or even suggest fees you manner mandate or even suggest fees you should consider for services rendered. This is should consider for services rendered. This is also an individual physicianalso an individual physician’’s decision.s decision.

Wellness Care vs. Medical CareWellness Care vs. Medical CareTHE Cornerstone IssueTHE Cornerstone Issue

These are INDEPENDENT These are INDEPENDENT examinations examinations –– have nothing to have nothing to do with each otherdo with each other

Can include some of the same Can include some of the same procedures, but they have procedures, but they have different findings and different findings and documentationdocumentation

Eye CareEye CareWe provide wellness care & medical care.We provide wellness care & medical care.

The decision to bill wellness or medical is The decision to bill wellness or medical is not solely based on why the patient is not solely based on why the patient is there or what their insurance coverage is.there or what their insurance coverage is.

It is determined over the entire course of It is determined over the entire course of the exam.the exam.

Medical CareMedical CareIt has nothing to do with:It has nothing to do with:

what special tests you orderedwhat special tests you orderedhow long you spend with the patienthow long you spend with the patientwhether a medical prescription was givenwhether a medical prescription was givenwhat the patient thinks is wrongwhat the patient thinks is wrongwhether the patient knew or didnwhether the patient knew or didn’’t know t know there was a problemthere was a problemwhether or not the patient needs vision whether or not the patient needs vision correction correction And it is And it is NOT limited to red eyes!NOT limited to red eyes!

Medical CareMedical Care

Reimbursed on cognitive thinking and the Reimbursed on cognitive thinking and the subsequent documentation of thesubsequent documentation of the……

SYMPTOMS AND THE SYMPTOMS AND THE ASSOCIATED ASSOCIATED DIAGNOSISDIAGNOSIS

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Medical CareMedical Care

Advantages:Advantages:Higher reimbursementHigher reimbursementPatient may pay less Patient may pay less –– espesp with Medicarewith MedicareValidation/Patient expectationValidation/Patient expectation

Disadvantages:Disadvantages:Get on panelGet on panelWait for reimbursementWait for reimbursementUnique rules Unique rules –– sometimes difficult to know sometimes difficult to know themthemFear of being auditedFear of being audited

Things to RememberThings to Remember……

Any time a patient presents to your Any time a patient presents to your office, you have to rule out a medical office, you have to rule out a medical problem before determining its a problem before determining its a wellness exam.wellness exam.Some medical insurances cover routine Some medical insurances cover routine eye care which usually reimburses eye care which usually reimburses higher!higher!LetLet’’s look at some key differences s look at some key differences between wellness between wellness vsvs medical care.medical care.

Wellness Care vs. Medical CareWellness Care vs. Medical Care

Reimbursement dictated Reimbursement dictated by by payorspayors

Reimbursement dictated Reimbursement dictated by YOU!by YOU!

Morbidity Morbidity –– potential potential mortalitymortality

No real morbidity, NO No real morbidity, NO mortalitymortality

Little to no Little to no ““Rules of Rules of examexam”” –– professional professional judgmentjudgment

““Rules of examRules of exam””cookbook and dictated cookbook and dictated by TOBby TOB

Reimbursement Reimbursement symptom or diagnosis symptom or diagnosis drivendriven

Reimbursement requires Reimbursement requires no driverno driver

MEDICAL CAREMEDICAL CAREWELLNESS CAREWELLNESS CARE







““Rules of examRules of exam”” cookbook cookbook and dictated by TOBand dictated by TOB

Reimbursement Reimbursement diagnosis or symptom diagnosis or symptom drivendriven























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Back to BasicsBack to BasicsPayorsPayors

There are five There are five payorspayors of eye careof eye care

1.1. PatientPatient2.2. Vision InsuranceVision Insurance3.3. Medical InsuranceMedical Insurance4.4. MedicareMedicare5.5. MedicaidMedicaid

PayorsPayorsPatientPatient

No rules apply!!!No rules apply!!!Can bill wellness or medical careCan bill wellness or medical careReimbursement is solely based on what Reimbursement is solely based on what youyou’’re willing to chargere willing to chargePaid todayPaid today

PayorsPayorsVision InsuranceVision Insurance

1.1. Few rules that govern the examFew rules that govern the exam2.2. DoesnDoesn’’t require a medical complaintt require a medical complaint3.3. Can use as a gateway to medical careCan use as a gateway to medical care4.4. Carries with it some amount of patient Carries with it some amount of patient

expectation thoughexpectation though

PayorsPayorsMedical InsuranceMedical Insurance

1.1. Some rules apply for covered benefitsSome rules apply for covered benefits2.2. DoesnDoesn’’t require a medical complaint, t require a medical complaint,

only a medical problemonly a medical problem3.3. Must have a medical diagnosis to justify Must have a medical diagnosis to justify

the exam and/or proceduresthe exam and/or procedures4.4. May have allowances for routine eye May have allowances for routine eye

care INCLUDING materialscare INCLUDING materials

PayorsPayorsMedicare onlyMedicare only

1.1. Lots of rules apply for covered benefitsLots of rules apply for covered benefits2.2. Must have a medical complaint*Must have a medical complaint*3.3. Must have a medical diagnosis to justify Must have a medical diagnosis to justify

the medical complaint to bill a medical the medical complaint to bill a medical exam and/or proceduresexam and/or procedures

4.4. Never covers routine vision exam or Never covers routine vision exam or refractionrefraction

What is a Medical Complaint?What is a Medical Complaint?

1.1. Medical symptom Medical symptom oror2.2. Physician directedPhysician directed followfollow--up based on up based on

a prior condition diagnosed ora prior condition diagnosed or3.3. History of eye problem diagnosed before History of eye problem diagnosed before

you and you and state in record that patient state in record that patient wants condition evaluatedwants condition evaluated oror

4.4. Few systemic problems Few systemic problems –– diabetes, high diabetes, high risk medication use, headacherisk medication use, headache

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What is a Medical Symptom?What is a Medical Symptom?

Almost anything other than blurred vision Almost anything other than blurred vision and sometimes that tooand sometimes that tooNOT a routine eye exam or yearly NOT a routine eye exam or yearly checkup or other such wordingcheckup or other such wordingCommonly overlooked symptoms:Commonly overlooked symptoms:

Floaters, glare, difficulty with night driving, Floaters, glare, difficulty with night driving, growths on eyes, fluctuating vision, itchy eyes, growths on eyes, fluctuating vision, itchy eyes, burning eyes, watery eyesburning eyes, watery eyes

PayorsPayorsMedicaidMedicaid

1.1. Follows most rules that apply to Follows most rules that apply to Medicare covered benefits but has some Medicare covered benefits but has some unique rules toounique rules too

2.2. Has allowances for medical care and Has allowances for medical care and routine eye care including materialsroutine eye care including materials

3.3. Medical billing doesnMedical billing doesn’’t require a t require a medical complaint, only a medical medical complaint, only a medical problemproblem

4.4. Can now bill for a separate refraction!Can now bill for a separate refraction!

Unique Unique PayorPayor RulesRules

Only way to find some of these rules out is Only way to find some of these rules out is to look it up, bill and see, or give up.to look it up, bill and see, or give up.

Medicare/Medicaid have Medicare/Medicaid have LCDsLCDs..Blue Cross Blue Shield does not pay for Blue Cross Blue Shield does not pay for corneal topography for any diagnosis.corneal topography for any diagnosis.VSP uses 92000 codes for wellness examsVSP uses 92000 codes for wellness exams

Local Coverage Determination (LCD)Local Coverage Determination (LCD)

Determined by the carrier (Trailblazer) and Determined by the carrier (Trailblazer) and change oftenchange oftenTypically limited to Medicare and Medicaid Typically limited to Medicare and Medicaid (although others may mimic)(although others may mimic)You MUST know and follow these limiting You MUST know and follow these limiting diagnosis rules or get denieddiagnosis rules or get denied

LCD ExamplesLCD Examples

““WOULD NOT EXPECTWOULD NOT EXPECT”” to perform to perform scanning laser at the same visit with visual scanning laser at the same visit with visual fields, fields, fundusfundus photography, Bphotography, B--scan or scan or extended ophthalmoscopyextended ophthalmoscopy

CANNOT perform more than one retinal or CANNOT perform more than one retinal or external photo at a given examinationexternal photo at a given examination

LCD ExamplesLCD Examples

Photos cannot just document existence of Photos cannot just document existence of a conditiona condition……must be used in the must be used in the diagnostic and treatment decision making diagnostic and treatment decision making processprocess

Repeat Repeat fundusfundus photos only used to photos only used to document change or progressiondocument change or progression

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Websites for your Favorites ListWebsites for your Favorites List

www.cms.hhs.govwww.cms.hhs.gov(Medicare)(Medicare)

http://www.cms.hhs.gov/NationalMedicareYouTrainhttp://www.cms.hhs.gov/NationalMedicareYouTrain(Learning Center)(Learning Center)

www.trailblazerhealth.comwww.trailblazerhealth.com(Carrier)(Carrier)

www.pgba.comwww.pgba.com(Palmetto)(Palmetto)

(commercial (commercial payorspayors usually have informational websites too)usually have informational websites too)

Numbers InvolvedNumbers Involved

CPT CPT –– Current Procedural Current Procedural TerminologyTerminology

What procedures you didWhat procedures you did

ICD 9 ICD 9 –– International Classification International Classification of Diseases, version 9of Diseases, version 9

What diseases you foundWhat diseases you found

CPT CodesCPT Codes99000 99000 Evaluation/Management ServicesEvaluation/Management Services92000 92000 General Ophthalmological ServicesGeneral Ophthalmological Services92000 92000 Diagnostic TestsDiagnostic Tests80000 80000 Laboratory TestsLaboratory Tests70000 70000 Radiology TestsRadiology Tests60000 60000 Surgical ProceduresSurgical Procedures

CPT Examination CodesCPT Examination Codes

Evaluation and Management Codes:Evaluation and Management Codes:New Pt: 992New Pt: 9920011, 992, 9920022, 992, 9920033, 992, 9920044, 992, 9920055Established Pt: 992Established Pt: 9921111, 992, 9921122, 992, 9921133, 992, 9921144, 992, 9921155

Ophthalmological Codes:Ophthalmological Codes:New Pt: 920New Pt: 9200022, 920, 9200044Established Pt: 920Established Pt: 9201122, 920, 9201144

44thth digit differentiates if itdigit differentiates if it’’s a new or established s a new or established ptpt55thth digit differentiates the level of the examdigit differentiates the level of the exam

ICD 9 CodesICD 9 Codes

Dry Eye SyndromeDry Eye Syndrome 375.15375.15CataractCataract 366.16366.16Type 2 DiabetesType 2 Diabetes 250.00250.00FloatersFloaters 379.24379.24

References:References:ICD 9 CM, 2008 office ed. ICD 9 CM, 2008 office ed. ©©2007. PMIC.2007. PMIC.EHR, EHR, EyeCOREyeCORhttp://icd9cm.chrisendres.com/http://icd9cm.chrisendres.com/

Coding and BillingCoding and Billing

Code to highest level of specificity Code to highest level of specificity ““best fitbest fit””

Use eye codes, not systemicUse eye codes, not systemicfew exceptions few exceptions –– headache, diabetes, etcheadache, diabetes, etc

Use the 5 digit version of the codeUse the 5 digit version of the codeOnly code what justifies the proceduresOnly code what justifies the procedures

If you diagnosis it, then you must treat it; but If you diagnosis it, then you must treat it; but you you dondon’’t have to code for it!t have to code for it!

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Coding and BillingCoding and Billing

There are many ways/styles of billing the There are many ways/styles of billing the exact same patient encounterexact same patient encounter

No one way is right/wrong or appropriate No one way is right/wrong or appropriate for every given patient encounterfor every given patient encounter

Legal to use different styles based on the Legal to use different styles based on the patient encounterpatient encounter

Styles of BillingStyles of Billing

Manage patient expectationsManage patient expectations

Manage office efficiencyManage office efficiency

Reimbursed for vision careReimbursed for vision care

Reimbursed for medical careReimbursed for medical care

General TipsGeneral Tips

Find out medical benefits before the examFind out medical benefits before the examSpecialist copay or CoinsuranceSpecialist copay or CoinsuranceProcedural copay (if there is one)Procedural copay (if there is one)DeductibleDeductible

How much they have metHow much they have met

Routine eye care allowanceRoutine eye care allowance

If Medicare patient, get a medical symptom!If Medicare patient, get a medical symptom!

Case ExamplesCase Examples

For medical exams, 92000 codes are the For medical exams, 92000 codes are the only examples used hereonly examples used here

For vision exams, S0620 code is usedFor vision exams, S0620 code is used

Example Example HCFAsHCFAs used here only site the used here only site the medical billingmedical billing

Health Health Insurance Insurance

Claim FormClaim Form(CMS 1500)(CMS 1500)

Case #1Case #1

48yo diabetic female presents with a 48yo diabetic female presents with a gradual decrease in her distance and near gradual decrease in her distance and near vision with her progressive lenses. She vision with her progressive lenses. She reports good control of her diabetes, but reports good control of her diabetes, but does notice her vision changes depending does notice her vision changes depending on her control. She has both vision and on her control. She has both vision and medical insurance.medical insurance.

Medical symptom?

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Medical RecordMedical Record

Refraction: Refraction: --2.00DS with 20/20 OU2.00DS with 20/20 OUSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--)DR)DR

Diagnoses:Diagnoses:Diabetes with ophthalmic manifestations Diabetes with ophthalmic manifestations (250.50)(250.50)Myopia (367.10)Myopia (367.10)

Billing Scenario #1Billing Scenario #1

Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using myopia (367.10) to vision insurancemyopia (367.10) to vision insurance

Collect vision insurance copayCollect vision insurance copay

Managed patient expectations

Not reimbursed for medical care

Billing Scenario #2Billing Scenario #2Bill a comprehensive medical exam (92004) Bill a comprehensive medical exam (92004) using diabetes with ophthalmic manifestations using diabetes with ophthalmic manifestations (250.50) to medical insurance(250.50) to medical insurance

Collect the medical insurance copay or monies going Collect the medical insurance copay or monies going toward deductibletoward deductible

Reimbursed for medical care

Not reimbursed for vision carePatient may question why vision insurance isn’t

being used and bill is higher

Billing Scenario #3Billing Scenario #3Bill a wellness vision exam (S0620) on initial visit Bill a wellness vision exam (S0620) on initial visit to vision insuranceto vision insurance


Bill an intermediate medical exam (92012) on Bill an intermediate medical exam (92012) on followfollow--up visit using diabetes with ophthalmic up visit using diabetes with ophthalmic manifestations (250.50) to medical insurancemanifestations (250.50) to medical insuranceBill extended ophthalmoscopy (92225Bill extended ophthalmoscopy (92225--RT/LT) RT/LT) using diabetes with ophthalmic manifestations using diabetes with ophthalmic manifestations (250.50) to medical insurance(250.50) to medical insurance

Collect medical insurance copay or monies going Collect medical insurance copay or monies going toward deductibletoward deductible


Reimbursed for all care delivered

Took 2 visits = more timePatient might not come back for 2nd

exam

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Case #2Case #2

67yo male presents with a decrease in his 67yo male presents with a decrease in his distance and near vision with his distance and near vision with his progressive lenses. He also complains of progressive lenses. He also complains of an inability to drive in the dark due to his an inability to drive in the dark due to his bad night vision. He has Medicare only.bad night vision. He has Medicare only.

Medical symptom?


Refraction: +2.00DS with 20/30 OD, OSRefraction: +2.00DS with 20/30 OD, OSSLE findings: 2+ NS cataracts OUSLE findings: 2+ NS cataracts OUDFE findings: unremarkable OUDFE findings: unremarkable OU

Diagnoses:Diagnoses:Cataracts, nuclear sclerosis (366.16)Cataracts, nuclear sclerosis (366.16)Hyperopia (367.10)Hyperopia (367.10)

Billing Scenario #1Billing Scenario #1Bill a wellness vision exam (S0620) using Bill a wellness vision exam (S0620) using hyperopiahyperopia (367.00) to patient(367.00) to patient

Collect UCR from patientCollect UCR from patient

Managed patient expectationsGot paid today

Not reimbursed for medical care and there was even decreased vision

Might have been able to save patient money by using his Medicare and you could had higher reimbursement


Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using nuclear sclerosis cataracts (92004) using nuclear sclerosis cataracts (366.16) to Medicare(366.16) to Medicare

Collect the appropriate monies based on Collect the appropriate monies based on unmet Medicare deductibleunmet Medicare deductible

Bill a refraction (92015) using Bill a refraction (92015) using hyperopiahyperopia(367.00) to the patient(367.00) to the patient

Collect UCR from patientCollect UCR from patient


Reimbursed for medical and vision care in one visitMay have saved the patient money depending

on Medicare deductible status

Patient may question why using Medicare, but maybe the conversation is easy due to the decreased vision aspect

Patient may also question why he has to pay for the refraction

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Case #3Case #3

29yo male presents with complaints of 29yo male presents with complaints of occasional flashes ever since a car occasional flashes ever since a car accident last week. No other real vision accident last week. No other real vision complaints that affect him daily. He has complaints that affect him daily. He has vision and medical insurance.vision and medical insurance.

Medical symptom?


Refraction: Refraction: --0.25DS with 20/20 OD, OS0.25DS with 20/20 OD, OSSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--))RDsRDs

Diagnoses:Diagnoses:PhotopsiaPhotopsia (368.15)(368.15)Myopia (367.10)Myopia (367.10)

Plan: RTC 1wk for Plan: RTC 1wk for f/uf/u





Not reimbursed for medical care and there is a real liability for a detachment


Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using (92004) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance

Collect the medical insurance copay or monies Collect the medical insurance copay or monies going toward deductiblegoing toward deductible

Choose not to bill refraction since patient Choose not to bill refraction since patient didndidn’’t really need glasses nor the potential t really need glasses nor the potential extended ophthalmoscopyextended ophthalmoscopy


Reimbursed for the medical care and higher reimbursement

Patient may question why you’re not using vision insurance, but maybe the conversation is easy due to the potential detachment issue

Could have billed extended ophthalmoscopy for higher reimbursement

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Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using (92004) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insuranceBill extended ophthalmoscopy (92225Bill extended ophthalmoscopy (92225--RT/LT) using RT/LT) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance

Collect the medical insurance copay or Collect the medical insurance copay or monies going toward deductiblemonies going toward deductible


Reimbursed for all the medical care and highest reimbursement

Patient may question why they have to pay all these charges instead of using the vision insurance and even more now for the extra test

Case #3 Case #3 –– Return VisitReturn Visit

Same patient returns 1wk later because Same patient returns 1wk later because you wanted to followyou wanted to follow--up on the continued up on the continued flashes. He has not seen any flashes flashes. He has not seen any flashes since his last visit.since his last visit.

Medical symptom?


Vision: 20/25 OUVision: 20/25 OUSLE findings: unremarkable OUSLE findings: unremarkable OUDFE findings: unremarkable OU, (DFE findings: unremarkable OU, (--))RDsRDs

Diagnoses:Diagnoses:PhotopsiaPhotopsia (368.15)(368.15)

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No charge visit No charge visit –– didndidn’’t bill patientt bill patient

Made patient happy without a bill

Didn’t get reimbursed for continued medical care


Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using using photopsiaphotopsia (368.15) to medical (368.15) to medical insuranceinsurance


Still chose not to bill extended Still chose not to bill extended ophthalmoscopyophthalmoscopy


Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using using photopsiaphotopsia (368.15) to medical (368.15) to medical insuranceinsuranceBill subsequent extended ophthalmoscopy Bill subsequent extended ophthalmoscopy (92226(92226--RT/LT) using RT/LT) using photopsiaphotopsia (368.15) to (368.15) to medical insurancemedical insurance



Reimbursed for all the medical care and highest reimbursement

Patient may question why they have to pay again for the same problem

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Case #4Case #4

52yo female presents with dry eye 52yo female presents with dry eye complaints. Its been oncomplaints. Its been on--going for years going for years without much help from artificial tear use. without much help from artificial tear use. Also feels like her vision has been affected Also feels like her vision has been affected by her dry eyes. She has both vision and by her dry eyes. She has both vision and medical insurance.medical insurance.

Medical symptom?


Refraction: +2.50DS with 20/25 OURefraction: +2.50DS with 20/25 OUSLE findings: 2+ diffuse SPK OU, 1+ SLE findings: 2+ diffuse SPK OU, 1+ diffuse conjunctival hyperemia OUdiffuse conjunctival hyperemia OUDFE findings: unremarkable OUDFE findings: unremarkable OU

Diagnoses:Diagnoses:Dry Eye (375.15) causing decreased vision Dry Eye (375.15) causing decreased vision

Plan: RTC 2wk for followPlan: RTC 2wk for follow--upup





Not reimbursed for medical care of dry eyes and there was decreased vision


Bill a comprehensive medical exam Bill a comprehensive medical exam (92004) using dry eye (375.15) to medical (92004) using dry eye (375.15) to medical insuranceinsurance


Waive the refraction feeWaive the refraction fee


Got reimbursed for the medical care delivered and waived the refraction fee to make life easier

Patient may question why their vision insurance isn’t being used and they have a higher copay

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Case #4 Case #4 –– Return VisitReturn Visit

Same patient returns 2wks later with Same patient returns 2wks later with improved symptoms, but still feeling like improved symptoms, but still feeling like eyes are dry.eyes are dry.

Medical symptom?

Billing Scenario #1Billing Scenario #1Since you billed the medical exam initially, bill a Since you billed the medical exam initially, bill a wellness vision exam (S0620) using wellness vision exam (S0620) using hyperopiahyperopia(367.10) to vision insurance(367.10) to vision insurance

Collect the vision insurance copayCollect the vision insurance copay

Patient understands that initially something was wrong, but now that everything is okay is getting to use vision insurance and pay less

Not reimbursed for medical care of dry eyes


Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using dry eye (375.15) to medical using dry eye (375.15) to medical insuranceinsurance

Decide not to collect the medical insurance Decide not to collect the medical insurance copaycopay……CANNOT DO THIS!!!CANNOT DO THIS!!!Must collect the medical insurance copay or Must collect the medical insurance copay or monies going toward deductiblemonies going toward deductible


Bill an intermediate medical exam (92012) Bill an intermediate medical exam (92012) using dry eye (375.15) to medical using dry eye (375.15) to medical insuranceinsuranceBill for Bill for punctalpunctal plugs (68761plugs (68761--E2,E4)E2,E4)



Get higher reimbursement and will help maintain patient’s eye health for longer period of time with plugs

Patient might have a problem with the costs involved in the medical care of dry eys

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How to Collect from MedicareHow to Collect from Medicare

Know MedicareKnow Medicare’’s fee schedules fee scheduleCannot charge Medicare more for covered Cannot charge Medicare more for covered service than private pay patientservice than private pay patient

How to Charge:How to Charge:2011 Annual Deductible ($162) then,2011 Annual Deductible ($162) then,Medicare pays 80% of covered servicesMedicare pays 80% of covered servicesPatient pays 20% of covered services and Patient pays 20% of covered services and 100% for any non100% for any non--covered servicecovered service

Example ChargesExample Charges

CPTsCPTs::92004 (exam)92004 (exam)9222592225--RT (ext RT (ext ophthalophthal))9222592225--LT (ext LT (ext ophthalophthal))92015 (refraction)92015 (refraction)

Total =Total =

Charges:Charges:$149$149$30$30$30$30$25$25$234$234

What are the covered services under Medicare?

Covered Services Total = $209Non-Covered Services Total = $25

Annual Deductible Met Annual Deductible Met –– NoNo

Covered Services:Covered Services:Patient Pays:Patient Pays:

$209 $209 -- $162 (deductible) = $47$162 (deductible) = $4720% of $47 = $9.4020% of $47 = $9.40$162 + $9.40 = $171.40$162 + $9.40 = $171.40

Medicare Pays:Medicare Pays:80% of $47 = $37.6080% of $47 = $37.60

NonNon--covered Services:covered Services:Patient Pays:Patient Pays:

$25 + $171.40 = $196.40$25 + $171.40 = $196.40

Annual Deductible Met Annual Deductible Met –– YesYes

Covered Services:Covered Services:Patient Pays:Patient Pays:

20% of $209 = $41.8020% of $209 = $41.80

Medicare Pays:Medicare Pays:80% of $209 = $167.2080% of $209 = $167.20

NonNon--covered Services:covered Services:Patient Pays:Patient Pays:

$25 + $41.80 = $66.80$25 + $41.80 = $66.80

Thank youThank you

Questions?Questions?

basics of medical versus z vision coding cpt and …texas.aoa.org/documents/tx/2011...

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