As surgical procedures become more common in optometry practices—either performing them ourselves or acting as comanaging physicians—medical record compliance and subsequent coding are areas of increasing concern.
• Medical record. Surgical procedures (minor or major) require a separate narrative in the medical record referred to as a surgical report. This typically describes the surgical procedure, preparation of the surgical field, instruments and approach used by the surgeon, and a statement of the patient’s status at the conclusion of the procedure.
• Coding. Coding a surgical procedure first involves recognizing whether it is designated as a minor procedure or a major procedure. This designation depends on the length of the global period assigned to the procedure itself: Minor surgical procedures have a global period of zero or 10 days and major surgical procedures have a global period of 90 days. This distinction is important to know because there are different medical coding conventions to be followed for each type of procedure.
When billing for a minor procedure, such as removal of a corneal foreign body, be aware that the office visit is included in the payment for the procedure.
While a few states allow optometrists to perform major surgical procedures, the vast majority of ODs perform minor surgical procedures on a daily basis, so let’s focus on these more common minor ones.
Office Visit Already Included
Perhaps the most common mistake that ODs make when submitting a claim for a minor surgical procedure is coding for an office visit on the same day as the minor surgical procedure. By definition, minor surgical procedures already include an office visit, so they should not be billed in conjunction with an office visit on the same date.
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services clearly delineates this for us: “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M [evaluation and management] services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.”1
However, if you have a signifi-cant and separately identifiable E&M service that’s unrelated to the decision to perform the minor surgical procedure, then you can separately report that E&M service with modifier -25. “The E&M service and minor surgical procedure do not require different diagnoses,” the NCCI policy manual states.1
The problem arises when ODs improperly use these modifiers just to get reimbursed for their office visit. The improper use of modifier -25 is a significant issue and has been the subject of investigation by the Office of Inspector General as being health care fraud.
Also, be aware that if you perform a minor surgical procedure on a new patient, the same rules for reporting E&M services apply. According to the NCCI policy manual, “The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”1
While surgical procedures are becoming more and more commonplace in the typical optometric practice, keep in mind that increased scope and privileges also require increased responsibility and compliance.
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1. Centers for Medicare & Medicaid Services. The National Correct Coding Initiative Policy Manual for Medicare Services. January 2014. Available at: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Accessed Sept 23, 2014. Accessed Sept 22, 2014.