2. Video 6 Filing 3 rd Party Claims 92000 vs. 99000 Addressing: Why the difference?Why the difference? Which Exam Codes Should I Use?Which Exam Codes Should I Use?

3. Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

4. Disclaimer The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

5. 4 99000 vs. 92000 In general, the 99000 codes are more concrete, requiring less subjective judgment In general, the 99000 codes are more concrete, requiring less subjective judgment But these concrete requirements may necessitate tests or procedures not required by comparable 92000 codes. But these concrete requirements may necessitate tests or procedures not required by comparable 92000 codes.

6. 5 99000 vs. 92000 The 92000 require a “diagnostic and treatment program” while the 99000 codes do not. The 92000 require a “diagnostic and treatment program” while the 99000 codes do not. When following a patient chronic conditions that require… When following a patient chronic conditions that require… no diagnostic testing and no treatment, no diagnostic testing and no treatment, …it is more difficult to code the 92000 codes. …it is more difficult to code the 92000 codes. The 92000 codes require documenting the patient’s “general constitution”. Not doing so prevents use of the 92000 codes. The 92000 codes require documenting the patient’s “general constitution”. Not doing so prevents use of the 92000 codes.

7. 6 99000 vs. 92000 Maximum Medicare reimbursement for a 92000 comprehensive exam is higher in some cases than an equivalent 99000 exam. Maximum Medicare reimbursement for a 92000 comprehensive exam is higher in some cases than an equivalent 99000 exam. Any such advantage is dependent on your U&C 92000 and 99000 fees. Any such advantage is dependent on your U&C 92000 and 99000 fees. – Many OD’s 92000 exam fees are not near that Medicare maximum, and to them there seems no $$ advantage in using the 92000 fees.

8. 7 99000 vs. 92000 But,if the OD’s 92000 examination fees are near or above Medicare’s maximum reimbursement level, then But,if the OD’s 92000 examination fees are near or above Medicare’s maximum reimbursement level, then – Provider must charge all patients that same amount. – Cannot charge a non-covered patient less. – Must charge all 3 rd parties the same amount.

9. 8 99000 vs. 92000 A discount for cash payment day of services by a self-pay patient is probably acceptable… …if it does not exceed 15% to 20%. …if it does not exceed 15% to 20%. Rationale: no billing or insurance claim expenses. Rationale: no billing or insurance claim expenses.

10. 9 99000 vs. 92000 Always Bill based on what is reasonable and necessary. Services must be performed and documented considering… Presenting Problem Presenting Problem History History Clinical findings Clinical findings

11. 10 99000 vs. 92000 Never examine and bill simply to maximize reimbursement rates… Never examine and bill simply to maximize reimbursement rates… To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges. To do so is fraudulent, and will lead to severe monetary penalties and possible criminal charges.

12. Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3 rd Party Educational Videos. 3 rd Party Services Nebraska Optometric Association