Dr. Wolfe shares an OCT photo from his practice. He says that there are nuances to coding for use of this instrumentation, which it’s important to be aware of.
Navigating NCCI edits in optometry
By Christopher Wolfe, OD, FAAO, Dipl. ABO
Oct. 9, 2024
Navigating billing can feel like a challenge, but understanding the National Correct Coding Initiative (NCCI) edits is key to keeping your practice compliant and financially healthy. These edits help ensure that claims submitted for reimbursement are correct and justified.
For optometrists, especially those performing medical-related services, understanding how these edits apply can mean the difference between getting paid or facing denials and audits.
What Are NCCI Edits?
NCCI edits are coding policies set by the Centers for Medicare & Medicaid Services (CMS) to prevent improper coding and over-billing. There are two primary types you need to know about:
- Procedure-to-Procedure (PTP) Edits: These edits identify pairs of procedures that shouldn’t be billed together. Think of it like bundling services—CMS wants to avoid paying twice for procedures that overlap.
- Medically Unlikely Edits (MUEs): MUEs place limits on how many times a service can be billed in a single day. They aim to prevent overutilization of services that wouldn’t reasonably need to be repeated multiple times in one visit.
For optometrists, NCCI edits become especially important when billing for diagnostic tests like fundus photography or OCT. Staying on top of these rules ensures claims get approved, and you stay compliant.
Why NCCI Edits Matter for Optometrists
- Avoiding Claim Denials
NCCI edits help ensure that billing is done correctly, which prevents claims from being rejected due to inappropriate code combinations.
For instance, CMS typically doesn’t allow you to bill for fundus photography (CPT 92250) and OCT (CPT 92134) together. I will discussed the -59 modifier in a future article, but in short, it should NOT be used to circumvent this NCCI edit.
- Ensuring Compliance
Adhering to NCCI edits keeps your practice compliant with Medicare rules. Incorrect coding doesn’t just mean a denied claim—it can also lead to audits or repayment demands, which can be both time-consuming and financially burdensome.
- Appropriate Reimbursement
By understanding and applying NCCI edits, you can ensure you’re billing for everything you’re entitled to, without running afoul of the rules.
For example, fundus photography (CPT 92250) and visual field (CPT 92083) can be billed separately from a comprehensive exam (920X4) if it’s distinct and necessary, as long as it’s well documented.
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Real-World Examples: PTP and MUE Edits
Procedure-to-Procedure (PTP) Edit Example
Scenario: You perform both fundus photography (CPT 92250) and OCT (CPT 92134) for a patient in one visit, thinking it’s a good idea to check the eye thoroughly.
The PTP Edit: CMS bundles these two procedures when performed on the same eye because they provide similar diagnostic information. The retina and optic nerve are considered part of the same anatomical structure, meaning using a modifier 59 to separate the services isn’t appropriate in this case.
What to Do: Obtain the tests on separate days OR obtain an ABN that assigns responsibility for payment of one of the tests to the patient since one of those tests will be denied.
Medically Unlikely Edit (MUE) Example
Scenario: You’re performing Visual Field Testing (CPT 92083) for glaucoma management. During the test, the machine stops working, and you only manage to test one eye. An “unlikely” scenario, but one that may apply.
The MUE Edit: In this case, since you only tested one eye, you would bill for a reduced service. To avoid over-billing, and to ensure proper reimbursement, you would use the -52 modifier, which indicates that the test was only partially completed.
What to Do: Bill 1 unit of CPT 92083 for the tested eye, but attach the -52 modifier to show that the service was reduced. This modifier tells Medicare you performed part of the service, which ensures you get paid appropriately without exceeding the MUE limit.
The Takeaway: Why You Should Pay Attention to NCCI Edits
NCCI edits are there to ensure accurate billing and to prevent over-payment or errors. For you, they mean fewer denied claims, compliance with Medicare and smooth sailing when it comes to audits. By following these edits and billing practices, you’ll help protect your practice and optimize your revenue cycle.
It’s all about being proactive. Train your staff, stay updated on CMS changes and ensure your billing and coding are as sharp as your clinical skills.
After all, the best care for your patients includes making sure your practice gets paid for the valuable services you provide!
Christopher Wolfe, OD, FAAO, Dipl. ABO, is the founder of EyeCode Education and the owner of Exclusively Eyecare, a Vision Source practice in Omaha, Neb. To contact him: drmoskweli@gmail.com
