Billing and Coding for Co-Managing Eyecare Patients

Aug 18, 2022
7 min read
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Working together with your local ophthalmology groups is a great way to build your practice and provide the best care to your patients. Billing and coding for co-management can be tricky. Implementing a system with your local ophthalmologists will provide the best clinical outcomes for patients as well as ensure both parties are properly compensated for their time and expertise.

In this article, we’ll explore the necessary steps to make billing and coding for co-management services easier! Below we’ll outline the process for ensuring a smooth co-management process for the patient as well as you, the provider!

What is co-management?

Co-Management is defined by the American Academy of Ophthalmology as “a relationship between an operating ophthalmologist and a non-operating practitioner for shared responsibility in the postoperative care period when the patient consents in writing to multiple providers, the services being performed are within the providers' respective scope of practice and there is written agreement between the providers to share patient care.”1

Step 1: Developing a protocol with clear communication

Like any relationship in life, communication is the key to success. From an insurance standpoint, the co-management relationship requires very specific forms and billing protocols to be followed. T’s must be crossed and I’s dotted, so to speak, or else no one gets reimbursed. By having clear communication and expectations with each patient and co-management provider, the process will be smooth for everyone.

The first question that has to be answered is who is seeing the patient for what appointments? You, as the optometrist, are doing the initial consult, but after the surgery, where will the patient go for their postoperative care? This can vary based on your OMD group as well as your comfort level as a practitioner. When co-managing cataract surgery, do you want to see the cataract patient at their 1 day post -op visit? The 1 week? The 1 month? Some surgeons prefer to see their patients at the 1 day visit.

This co-management system should also include automated scheduling of all necessary post-op visits on the same day as the patient’s surgical consultation. The ophthalmology surgical coordinator should have direct contact with your office and call to schedule all appropriate follow-up visits when necessary. This takes away any responsibility from the patient and ensures the patient will be seen for their necessary post-operative care.

In addition to this appointment schedule, there has to be a specific paper trail between you and the ophthalmologist.

These forms include the following:

  • Initial referral form from OD to OMD
  • Patient election for co-management form*
  • Transfer of care form *
  • Post-operative assessment sheet

*Required for billing.

Both the patient election for co-management and transfer of care form are required if you are going to be reimbursed for co-management services. These forms must be signed by the patient and kept within the patient’s medical records.2

The Transfer of Care Form must have the following information:

  1. Patient name
  2. Operative eye
  3. Nature of operation
  4. Date of surgery
  5. Clinical findings
  6. Discharge instructions
  7. Transfer date

Step 2: Understanding billing for co-management

How do you get paid for your time and co-management? The most important thing to remember here is in the details: CPT codes, modifiers, and transfer of post-op care date.

Most patients that undergo cataract surgery will be using Medicare, so let’s use them as a billing example. On the day of the surgery, the surgeon will likely bill out CPT code 66984 with modifier 54. Modifier 54 indicates the surgical event is a co-managed case.

The optometrist will then bill out CPT code 66984 with Modifier 55 on the date that they see the patient, which indicates post-op management only. Do not use any 99XXX or 92XXX codes for these patients.

You should use the modifier RT/LT to indicate which eye was operated on.

Medicare also requires providers to write in the ‘additional claim information ’ (line 19) of their CMS-1500 form that date of when care was assumed by the doctor and when it was relinquished.

Additionally, most patients will undergo surgery for their second eye during this ‘global period.’ Modifier 79 is used to identify that the surgery is unrelated to the first eye.

NB: You can see the patient for an alternative reason during this time and bill out appropriately; for example, if they get a foreign body in their eye.

Click here for an example of a CMS Form filled out for co-management.3

Step 3: Understanding reimbursement

Medicare assigns 80% of the reimbursement to the intraoperative service, so 20% is left for our co-management. Within that 20% Medicare splits it between co-managing providers based on the number of days each provider is responsible for the post-op care during the global period (90 days post-op).1,2 Item 24G of the claim form should be filled out with the number “1” OR if the carrier requires, put the number of post-op days.

NB: If the surgeon does all the follow-up care and they refer back to you for the refraction only, this does not count as co-management. You should bill appropriately for the refraction.

Advanced technology IOLs and insurance reimbursement

Currently, insurance covers only basic IOL implants. As the co-managing doctor, it is encouraged to discuss all the options with your patients, including premium IOLs (astigmatism correction, multifocal correction) and the addition of laser, that will have the best visual result. The patient is responsible for these costs (make sure they sign an advance notice of non-covered services) and depending on the relationship with your co-management provider, you may be eligible for additional compensation for the increased level of care required with these options.

Other co-management opportunities

Specializing in vision therapy and rehabilitation, I do work with our local strabismus surgeon. The protocol varies based on the case, but I am an advocate for pre-surgery vision therapy, surgery, and then post-surgery vision therapy in certain cases to decrease the likelihood of regression of cosmetic alignment by promoting and developing stereopsis and overall, more stable binocular function.

For all other surgical procedures (eg. blepharoplasty for ptosis), I discuss with the patient why I am referring and when I want to see them back in our office to ensure we are not losing them as patients.

From a billing standpoint, this is much more straightforward as there is no ‘co-management’ in the eyes of the insurance with these procedures. You bill out appropriately for your exams and follow-ups as you normally would using 99- or 92- codes.

Last words on co-management

As optometrists, our scope of care can be of great service when caring for patients undergoing cataract surgery. Working with our ophthalmology colleagues has the added benefit of growing our practices while also providing patients with the best possible care. Through building co-management relationships, optometrists play an integral role in the healthcare team. When seeing patients for postoperative care, it is crucial to implement and optimize a referral, billing and coding process for proper reimbursement.

Be sure to seize the co-management opportunities in your area!

References

  1. American Academy of Ophthalmology. Comprehensive Guidelines for the Comanagment of the Postoperative Care. September 7, 2016 Accessed June 12, 2022. https://www.aao.org/ethics-detail/guidelines-comanagement-postoperative-care
  2. Richman, H and Wartman R. Cataract Co-Management for Billing for Medicare. American Optometric Association. https://www.aoa.org/documents/optometric-staff/articles/cataract%20co-management.pdf Accessed June 12, 2022
  3. Alcon.CataractCoManagementGuide.6.20.pdf (myalcon.com)
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About Miki Lyn Zilnicki, OD, FCOVD

Miki Lyn Zilnicki, O.D. graduated with honors from the SUNY College of Optometry in New York, receiving the VSP Excellence in Primary Care and Excellence in Vision Therapy awards. She then continued her education by completing a residency in vision …

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