Billing & Coding In Your Optometric Practice: Q&A
By: Jason R. Miller, OD, MBA, FAAO
PECAA Member Since 2012
In this PECAA Blog post, Dr. Jason Miller reviews a couple common billing and coding questions. Many of these questions are issues that many offices are facing so you are not alone.
Q: We recently heard of practices in surrounding areas offering certain discounts on their exams. My question is whether or not prompt pay discounts legal?
The only acceptable discount to offer is a prompt pay discount if it is offered to all patients even if they have insurance. Most payers understand the acceptability of prompt pay discounts while their contracts often require doctors to bill them using their usual fees, effectively prohibiting doctors from providing discounts to patients simply because they are private pay. It is understood that providing discounts to patients without insurance essentially creates a new usual fee from which payers will then take their discounts. Prompt pay discounts must be given in exchange for payment on the same day of service. The discount should not be more than 20% of the usual fee and may be either for services, materials, or both. Medicare’s policy is that they pay the lesser of the doctor’s usual charge or the Medicare Fee Schedule amount. Most insurers believe that ‘usual’ equates to the charge you would bill to a private pay patient.
Additionally, occasional discounts are all right for any reason, as long as they don’t create a pattern. For example, a doctor can provide a discount of up to 100% in special circumstances, such as for clergy or good friends or for the indigent. It is dangerous, however, to provide discounts for a significant percentage of one’s practice unless such discounts comply with the rules of prompt pay discounts (alternatively termed cash discounts, day of service discounts). The significant percentage is believed to be in the range of 35% of the total practice.
Q: Can I bill an office visit 99213 with superficial conjunctival foreign body removal (65205)? If 99213 can be billed should I add a modifier? If so, which modifier is appropriate?
If the reason for the visit was something different than the finding of or subjective complaints associated with that foreign body, then yes. The surgical code, 65205, includes the finding of the foreign body and is reimbursed at a higher rate because of that. If the patient is in for a different reason, then billing a 99xxx code or 92xxx code with a different diagnosis and attaching Modifier 25 would be appropriate.
Modifier 25 = Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.
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