Medicare Reimbursement for Ophthalmic Diagnostic Tests

Diagnostic tests are useful to the physician in the diagnosis and management of disease. In CPT, many ophthalmic tests are found in the section entitled Special Ophthalmological Services. These CPT codes describe procedures above and beyond a general eye examination and are usually treated discretely for reimbursement purposes. In addition, some radiological tests are useful…

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Billing Office Procedure Manual

The practice of medicine has undergone many changes during the past decades, not least of which is management of the practice. Numerous journal articles and books have been published on practice management and we will not attempt to recreate them here. While many are truly useful, too often they describe what results are needed and…

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Medicare Reimbursement for Presbyopia-Correcting and Toric IOLs

Most intraocular lenses (IOLs) contain only spherical power and do not correct for presbyopia. Some IOLs contain sphere powers for both distance and near, and are known as presbyopia-correcting IOLs (P-C IOLs). Other IOLs also contain cylinder power for correction of astigmatism; they are known as toric IOLs or astigmatism-correcting IOLs (A-C IOLs). Some IOLs…

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Medicare Reimbursement for Post-Cataract Eyeglasses

Medicare does not usually pay for eyeglasses or contact lenses. However, if the beneficiary is aphakic (H27.0-), congenitally aphakic (Q12.3), or pseudophakic following cataract surgery (Z96.1), then glasses or contact lenses are a benefit under the portion of Medicare law covering prosthetic devices. These claims are frequently longer and more involved than claims for physicians’…

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Co-Management of Postoperative Care

The debate about co-management of surgical postoperative care began in 1992 with landmark changes in Medicare payment to physicians, and continues today. Legal, medical, and economic issues are involved. The government’s concern over possible abusive referral arrangements and violations of federal and state anti-kickback statutes continues. While co-management of cataract postoperative care is the single…

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Rules for Modifiers

This publication provides a detailed discussion about modifiers used in billing ophthalmic services. An overview of the monograph is discussed below. Modifiers on claims provide additional information about the service or procedure performed. They are used as an extension to alter or “modify” a CPT code but not change the code or its definition. Modifiers…

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Medicare Reimbursement for the ASC

The delivery of eye care services has undergone many changes in recent years. In particular, ophthalmic surgeons now perform major procedures in an ambulatory surgery center (ASC) more often than in a hospital outpatient department (HOPD). Within the Medicare system, eye surgery ranks in the top three groupings of ASC services; the other two popular…

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Medicare Reimbursement for Surgical Procedures

Numerous regulations apply to claims for surgical procedures. This monograph contains a detailed discussion about medical necessity, physician utilization of surgical services, global surgery rules, and a myriad of coding and documentation issues associated with ophthalmic surgical procedures. Understanding these issues helps ensure quality documentation, cleaner claims and proper payment for the service(s) provided.

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Reimbursement for Fundus Photography in Telemedicine

Telemedicine is the remote diagnosis and management of patients by means of telecommunication technology. In eye care, digital fundus photography (FP) lends itself to successful telemedicine1 because the camera can be placed in a primary care physician’s (PCP’s) office and operated by the PCP’s staff. Then, the images are transmitted to an ophthalmologist or optometrist…

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