Miscellaneous Info on CPT Codes & Other Related Issues

Medical Decision Making

There are three components to medical decision making. And the third component has three parts.

1. Number of diagnosis and managment options. For each diagnosis (problem) you need to determine if the problem is:

* self-limited or minor: stable, improved, or worsening
* established problem; stable or improved
* established problem; worsening
* new problem; no additional workup planned
* New problem; additional workup planned

2. Amount and/or complexity of data

* review and/or order clinical lab tests
* review and/or order radiology/untarsound tests
* review and/or order medical tests
* discuss tests with performing physician
* independently review image, tracing, or specimen
* decide to obtain old records and/or additional history from someone other than the patient
* review old records and/or additional history from someone other than the patient

3. Table of risk - which includes a guide to determine the level of risk for each presenting prolem, each diagnotic procedure and each management option.

The AAO has just released the E&M Internal Chart Auditor for Ophthalmology CD rom. It is very helpful in letting you know what level of exam you've documented.

Questions Submitted by Members' Offices

Q. Has the description for 67220 been removed in CPT this year? And can we charge for 67220 with modifiers if we documented a new area?

A. Unfortunately a change did not occur in the description of CPT. The AAO has found that there are many local carrier determination that allow a second treatment of CPT code 67220 if well documented showing it is in a different area or for a different condition within the 90 day postoperative period. Proceed with caution and check directly with your carrier.

Q. I have been denied payment by Medicare for the following codes:
- 92135 - CO16 and M73
- 92081 - CO16 and M73
- 92083 - CO16 and M73
- 92250 - CO16 and M73
Note: M73 ... the HPSA physician scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical component.
Note: M16 ... Claim/Service lacks information which is needed for adjudication. Additional information is supplied using remittance advice.

Q. We are NOT located in a HPSA bonus area and Medicare has never required us to list these procedures with TC and 26. What can we do?

A. This office is coding correctly since they are not in a scarcity bonus area. If it were a shortage area, coding for each of the codes listed below should be (for example)
- 92135-26 and a modifier like QB identifying it as a bonus area. 92135-TC. However, in situations like this, it is adviseable to call your Medicare carrier representative for more details.