Denial-0ptometry

[Pay_My_Claims]

OK, need my Opthalmology & Optometry specialist on this one.  My provider is getting major denials from Medicare billing 92004 with dx 401.9 (hypertension unspecified).  It is denying for medical necessity. Since Medicare does not cover routine eye exams, I believe he needs another dx to justify the exam. EX, if they had blurred vision which was a result of the HTN  etc am I correct? Now I am not asking you to give me DX for him to use to get the claim paid, I know thats fraud. Medicare will flag it if he doesn't have documentation, just looking for some advice

Thanks

[medauthor]

Pay,

Have you seen this site?  http://chppm-www.apgea.army.mil/doem/coding/PRIMER.ASPX

[Pay_My_Claims]

Yes, been on that often, thanks though MedA

[oneround]

Char, have you checked the LMRP for your state?  Some DX's when billed with 92004 require two or more CPT's and or DX's

[Pay_My_Claims]

yes, the issue is there is no "chief complaint" the 401.9 is a DX, and for Medicare to pay for an eye exam it needs that. You can do a glaucoma screening or a diabetic exam, but to code with that, denies for medical neccesity.

[Michele]

It may just be that the doc doesn't realize he should be coding the complaint along with the reason.  Like you said, pt states "I have blurred vision and high blood pressure"  both should be on the claim.  The doc may think "well the blurred vision is due to the high blood pressure" and just put the high blood pressure.  Maybe education is the answer.

[Pay_My_Claims]

Thanks Michelle, yes I notified him, and his partner and sent him the Medicare guidelines on it. HTN is factor in vision issues, but it is not a dx that I am currently aware of that Medicare allows as a reason for an eye exam. The only 2 that I know is for glaucoma, and diabetes.
thanks for everyones input

[Michele]

They allow for alot more than that, diabetic retinopathy, dry eye, visual floaters, way too many to name.  We've been billing for OD's to Medicare for 15+ years.

[Tilbrook]

I second Michele -- Medicare will pay for many more diagnoses than diabetes or glaucoma.  Our ophthalmologists bill Medicare for the majority of their patients.  You are correct that a medical diagnosis is needed, as Medicare will not pay for a routine eye exam.  Most insurance companies won't in fact.

[Pay_My_Claims]

 @ Tilbrook Yes, and i wasn't saying they were the ONLY dx they cover for, but the guidelines that are automatically covered are for the diabetic yearly exam, and for history of glaucoma.  I was thinking I was correct when I emailed the optometrist that I needed a complaint dx that 401.9 did not justify medical necessity for payment on the claims.

[DMK]

Just to help further my education, does the OD need a referral from the PTP to get this paid?  In our line, for example, the PTP must order any x-rays, MRI, CT's in order for Medicare to pay.

[Pay_My_Claims]

what is a ptp??

[DMK]

Primary Treating Physician

[Pay_My_Claims]

thats new on me, never heard that term *writes it down*

[Michele]

No referral is needed for Medicare to pay for an eye exam for a medical reason.