Where coding and coverage intersect: Tips to keep your practice up to date

Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., Rebecca Wartman, O.D.

Excerpted from page 40 of the July/August 2018 edition of AOA Focus.

The AOA provides many resources to ensure doctors of optometry understand the appropriate codes to report for the procedure performed and diagnoses treated. Additionally, Current Procedural Terminology (CPT)® requires that doctors should "select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided." Likewise, the provider should select the most precise ICD-10 diagnosis for the condition observed and treated.

While accurate coding is paramount, doctors also need to be aware of coverage policies that may impact how you report services provided to your patients. Here are some commonly asked questions regarding coverage concerns.

How are changes to Medicare policies regarding coverage made?

Medicare Administrative Contractors (MACs) make changes to coverage policies through Local Coverage Determinations (LCDs). You can access your state's LCDs through the Centers for Medicare & Medicaid Services (CMS) website or your local MAC.

I thought Medicare developed National Coverage Determinations; how can individual MACs make changes?

CMS clarifies, "MACs may develop an LCD to further define a National Coverage Determination (NCD) or, in the absence of a specific NCD, to establish the permissible indications for the performance of a procedure according to evidence-based guidelines. An LCD is a coverage decision made at a MAC's own discretion to provide guidance to the public and the medical community within a specified geographic area. An LCD cannot conflict with an NCD. An LCD is an administrative and educational tool that can assist you in submitting correct claims for payment by: outlining coverage criteria; defining medical necessity; and providing references upon which a policy (LCD) is based and codes that describe covered and/or noncovered services when the codes are integral to the discussion of medical necessity.

Who writes LCDs?

LCDs are written by the medical directors of a MAC and are presented for discussion by the Carrier Advisory Committee (CAC), which is composed of delegates from all medical specialties. Optometry is represented on the CAC in each of the jurisdictions and has helped to shape coverage policy for services within our scope of practice. Contact your state association to find out who your CAC representative(s) is or are.

When has an LCD change impacted optometry?

In 2017, some Medicare contractors made policy changes to coverage for the use of visual evoked potential (VEP) or electroretinography for either glaucoma diagnosis or management. The policy change deemed the use of VEP or ERG for glaucoma "investigational" and therefore unpayable. Another common and clinically useful service, optical coherence tomography, was recently revised and changes were made to certain clinical indications, the frequency with which the service may be performed and the coverage for other diagnostic tests performed on the same date of service. Generally speaking, the diagnostic indications listed in the LCD will guide coverage for the service while subject to other correct coding guidelines (CCI edits) and frequency limitations.

How can I keep track of coverage changes?

Offices should periodically verify LCDs and coverage policies from insurance companies to check for changes. Be sure to review email notifications for insurers regarding coverage changes. Make it a habit to keep a bookmark on the billing computer to make sure that all references are current. The unfortunate reality is that even with appropriate coding, denials and delays in payment can occur. Being proactive and reviewing coverage policies can help in staying abreast of changes.

Need coding help? Access AOA resources

AOA Coding Today is an online, comprehensive database that contains information in real time for CPT, ICD-10 and Healthcare Common Procedure Coding System coding and research. The website is tailored specifically to optometry and assists doctors and staff in correct reimbursement and compliance, and has an easy-to-use code diagnosis ability based on region. Visit aoa.codingtoday.com to assist you immediately with your coding questions.

If you have specific coding questions that are not addressed through AOA Coding Today, direct them to AOA's coding experts by completing the online web form.

If you have suggestions for how AOA can best support the coding needs of doctors of optometry, please contact Kara Webb, AOA's associate director for coding and regulatory policy, at kcwebb@aoa.org or 703.837.1018.