Billing and Coding Q&A

Q: What is the proper ICD10 code for a patient with physiological cupping of optic nerves in a patient without glaucoma? I don't want to label them as glaucoma suspect but I would like a code so I can bill an OCT.

A:  There is no ICD10 code that is going to fit physiological cupping without giving a dx of glaucoma or glaucoma suspect. The closest code that is not glc suspect code would be "glaucomatous optic atrophy." 

I understand that you may not want to label the patient a glaucoma suspect, but that is why you are doing the OCT. If you knew they just had large cups, you wouldn't need to do the OCT. You are doing it because you suspect glaucoma...therefore, they are a glaucoma suspect.‚Äč

Q: I was wondering if anyone could give me some information regarding Medicaid billing.  I recently started accepting Medicaid.  When I bill a comp eye exam 92004 along with refraction 92015 the refraction component is denied.  When I contacted Medicaid about this I was told that the refraction would be denied based on the same day of service for both codes.  I could not get an explanation about this other than I was told that is Colorado State guidelines.  

A: Unfortunately this very well could be the case. Although we all know that 92015 is NOT part of any other code, some payers have chosen to bundle it. It does not make sense that they do this, but some do. Unfortunately, if that is the payer's decision, you will want to make sure to create a new 92004 that also bundles both of the those fees. I assume Medicaid reimburses less than you would charge, but you will still want to bill them for the full amount so you can more accurately assess the financial impact they have on your practice by accepting them.

For example, if you normally charge $100 for 92004 and $30 for 92015, you will want to create a "Medicate 92004" billed at $130. I hope that makes sense. It is quite frustrating when individual payers choose to make up their own rules, and we have to figure them out.

There is one other possibility. Many Medicaid payers will only reimburse for one service code per day. We typically see this when a patient as a condition like glaucoma and  they need the office visit plus a VF and an OCT. If you bill them all the same day, they will only pay one. But, if you have the patient return on separate days for each service, they will pay them all. They do this to minimize utilization because they truly don't have enough money. With this said, I have not run into the situation when they deny the refraction and an exam. Perhaps they require you to bill the exam and refraction as "routine" with Z01.00 to utilize the patient's yearly benefit. If you bill the exam with a medical dx, they may then default to the "one per day" model of care. Not being CO doctor, I am not sure. But I would suggest calling the payer and asking how you are suppose to code for a routine exam benefit. It could simply be that you need to use a different ICD-10 code.  

Q: What is the proper way to code/bill a second visit for a continued eye exam?

Example: Patient comes in for an annual complete eye exam but either we could not complete(uncooperative child) or patient did not want to be dilated that day but later.

What is the protocol for coding that second visit of continued care for a Medicaid patient? 

A: The definition of 920X4 states that the dilation can be done on the same day or another day. So, you can't bill for the return visit. This is especially true for Medicaid patients.


Q: I performed a macular threshold visual field on a patient who has taken Plaquenil long-term and I am having trouble with the ICD-10 code, since there is no pathology present.

A: For coding of baseline testing of high risk meds you need to code Z79.899 and the systemic disease associated with taking the medication. i.e. RA, Lupus... There is no need for any other code when there is no disease.


Q: I am starting an ocular prosthetics clinic in CO and need help with billing. Typically this is covered by Medicare/ some medical insurances. I found the V2623 code for the prosthetic eye itself, but cannot figure out if that is a global code to cover the fitting and device or if I can bill 92-/intermediate codes for each fitting visit.

A: I believe V2623 is a global fee that covers the materials and services.

Code V2623:

  • Evaluation and impression of the ophthalmic socket
  • Development of a fitting model or pattern (in acrylic plastic or wax)
  • Painting the iris and sclerotic colorings to replicate the anatomical characteristic of the fellow eye
  • Finishing
  • Delivery of the competed prosthesis
  • Six months follow-up care

  Q: Our office is relatively new to Medicaid and I am wondering if we should be billing the refraction or not?  I have been billing Medicaid and they deny the code, so I have been charging patients (over age 21) the $2 copay + refraction fee.  I cannot find anywhere on the website if we should do this or not and it seems that a couple of my colleagues are not charging patients the refraction.  I guess I was just following what I would do with Medicare.  What is the proper charge for patients? 

A: Every payer is different, so I do not have direct experience with the Medicaid program in Colorado. In the end, I will suggest you contact the Policy and Billing department and ask how they want you to handle 92015. Many payers still bundle the refraction into the exam charge. This is completely wrong because the refraction has been a separate code for decades, but several still do it that way. So in these situations, they may simply combine the two into the code 92004/14.

My concern with you charging the patient directly for the refraction is that it is possibly a violation of the contract. Most Medicaid programs do not allow you to charge patients out of pocket for services they deem non-covered. For example, in Wisconsin when a Medicaid covered patient has cataract surgery we are not allowed to charge the patient for the final refraction, even though Medicaid does not pay it.


Q: A patient has been seen  for infection DX. Do the visits need to be coded with initial visit, subsequent encounter. Do infection DX that have follow up visits need subsequent code?

A: The only ICD-10 codes that require initial (A), subsequent (D), and sequela (S) modifiers are the trauma codes. As you can see in the attachment, corneal abrasion (S05.0) states in the pink box that it requires one of those 7th characters, where as conjunctivitis (H10) does not have that information. If you don't already have the AMA Official ICD-10 Codebook, I recommend you order it. The 2016 version is out now.

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