RETINOPATHY: AN INTRODUCTION
It is disconcerting to know that more than 10 million Americans have some form of retinopathy, of which the majority of cases are tied to diabetes and diabetic complications. Diabetic Retinopathy is also the leading cause of loss of vision among working-age adults in the U.S.
Sometimes referred to as ‘retinal disease’ or ‘retinal damage’, retinopathy can actually be of different kinds, depending mainly on the condition that causes it. The most common variant is, of course, Diabetic Retinopathy, which is caused by diabetes. Other less prevalent types include hypertensive retinopathy, caused by hypertension (high blood pressure), Sickle Cell retinopathy which is linked to sickle cell disease, and Retinopathy of Prematurity (ROP) which is seen in premature infants.
BILLING FOR RETINAL TREATMENTS: CHALLENGES
Belonging to the branch of medicine known as Ophthalmology that deals with eye care, billing for retinal care comes with its own set of challenges and complexities. Here are some areas where providers face the strongest impediments when it comes to collecting reimbursement from their patients’ health plans.
Prior authorization tops this list. Many injectable drugs (like Avastin, Lucentis, Eylea) that are often used in treating retinal diseases, require prior authorization on a strict basis. The real challenge is in the fact that each payer has a different set of requirements when it comes to prior authorizations. Keeping abreast of them all can often overwhelm practices with inadequate billing-desk personnel.
Billing for retinal care is also notorious for inviting frequent denials. These arise, in most cases, from mismatch between the diagnosis and the treatment, incomplete chart notes, and lack of supporting imaging (e.g., OCT). In many cases, a high denial rate can be attributed to coding inaccuracies. It is important to remember that certain procedures (e.g., intravitreal injections) must be paired with the correct modifiers and diagnosis codes.
FURTHER CHALLENGES
CMS and private payers regularly update Local Coverage Determinations (LCDs) and guidelines for medical necessity. When a provider starts drafting a claim without being aware of these changes, there is a high risk of denial.
Some codes in particular, due to their high-value nature and frequency of use, are closely scrutinized by payers. If adequate documentation for medical necessity is missing, claims containing these codes can be denied. Some of such CPT codes include:
- 67028 Used for intravitreal injection of a pharmacologic agent
- 92250 Applies to fundus photography with interpretation and report
- 92134 Used for scanning computerized ophthalmic diagnostic imaging (e.g., OCT)
- 67210 Used to describe focal laser photocoagulation
- 67228 Applicable for panretinal photocoagulation
Examples of some ICD-10 codes flagged frequently for documentation issues include:
- H35.321 (Exudative age-related macular degeneration, right eye)
- H35.371 (Retinal neovascularization, right eye)
- H35.00 (Background diabetic retinopathy, unspecified eye)
- E11.329 (Type 2 diabetes with mild nonproliferative diabetic retinopathy without macular edema)
- H35.81 (Retinal hemorrhage)
- H34.811 (Central retinal vein occlusion, right eye)
SUNKNOWLEDGE: YOUR TRUSTED PARTNER IN BILLING FOR RETINAL DISEASES
Building and maintaining an efficient billing practice often become a costly and difficult proposition for ophthalmologists. Outdated methodologies, inefficient operations, staff irregularities, high remuneration – in-facility billing is prone to many dangers.
It is only natural that a growing number of eye-care practices in the U.S. are opting for offshore outsourcing. This strategic move, at once, opens up fantastic possibilities for increased productivity, cost saving, and improved outcomes.
Try SunKnowledge if you are considering outsourcing your billing, coding and other RCM operations.
We provide end-to-end RCM support for healthcare providers, including:
- Patient Intake
- Eligibility Verification
- Prior Authorization
- Coding
- Claim Review/Claim Scrubbing
- Accounts Receivable Management
- Denial Management
- Payment Posting
- Virtual Assistance, and more
“I wanted to give a shout out and special thanks to the collectors for all of their hard work and efforts as we have finally moved from the red and are now in the green for backlog. Keep up the great work!”
Opt for comprehensive support, or pick the specific areas where you seek assistance. We will be glad to share a customized plan with you to get you started immediately.
TURBOCHARGE YOUR RETINAL CARE BILLING WITH SUNKNOWLEDGE
Choosing SunKnowledge as your dedicated billing and RCM partner comes with a host of benefits. Our ability to work as a true, seamless extension of your billing team makes us unique as a retinopathy billing specialist. Providers prefer us to other RCM companies for our high productivity, industry-leading accuracy, and unmatched affordability.
With us, you are always assured of:
- 97% first-pass rate and up to 80% reduction in collection costs (compared to in-facility)
- Trained billers, certified coders and other skilled RCM personnel
- Dedicated teams assigned solely to one account
- Free transition, audits, and Account Managers
- Free 15% buffer workforce for uninterrupted workflows
- Deep RCM insights derived from our rich payer-side work experience
- No binding contracts and easy, 30-day exit option
- Excellent references in multiple specialties from across the U.S.
- Full support at an all-inclusive rate of $7 per hour, with no hidden charges
“It’s been a great year, and I’m incredibly proud of this team. Despite many changes and challenges, you’ve handled everything with strength and unity. Your hard work and teamwork make all the difference.“
THE NEXT STEPS
Get in touch with us by using the form below. Consult us on a discovery call and let us show you how we can multiply your collections with a customized action plan.