Medicare Compliance & Reimbursement

Often, ophthalmologists don't take full advantage of the Medicare market since many patients need only routine, non-covered services, such as refractions and routine check-ups. But wait: You can serve the Medicare patients in your area and get paid if you follow these three simple rules from our experts:

Of course your ophthalmologist can't -- and doesn't -- manufacture patient complaints. But it is appropriate to ask patients follow-up questions to extract an accurate and complete history which may glean relevant information -- and potentially discover that an office visit is benefit-eligible.

Payment rules: Medicare will not cover examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury. For instance, a refraction test (92015, Determination of refractive state) is a type of non-covered service that is typically unrelated to diagnosing some specific eye complaints. Routine eye exams, sometimes coded as S0620 (Routine ophthalmological examination including refraction; new patient), are also not covered. However, your physician may bill Medicare for the encounter if your patient presents with a covered problem that establishes a medically necessary diagnosis and treatment.

Tip: Probe gently for a complaint, but take care to avoid force-feeding one, suggests Raequell Duran, CPC, president of Practice Solutions, a coding, compliance, and reimbursement consulting firm based in Santa Barbara, Calif.

Not covered: If a patient says he needs new glasses, of course Medicare will not cover the visit because it is seemingly unrelated to a specific illness or symptom.

When appropriate, think about training your front-desk staff to ask a follow-up question to uncover the true nature of the visit. Consider asking "Why do you feel you need glasses?" or "Are you having problems with your distance vision or trouble reading the computer screen?"

Covered: An example of a covered visit would be if the patient responded by complaining of "decreased visual acuity, distance and near, gradual decrease - 6 months, both eyes," Duran remarks.

"If the patient is complaining of a change in his vision, you should be able to find a reason for the change," notes David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

"More than likely, there will be a medical reason for the change, but if it is a refractive-only change, Medicare won't cover it." But in Medicare patients, it is generally early cataracts (366.xx, Cataract) driving the refractive change, which Medicare does cover, he points out.

Vital: Remember that you must code according to the office visit's initial purpose, regardless of the visit's ultimate findings, Duran points out. For instance, if a patient complains of eye injury or discomfort, Medicare will cover the resulting services (except for eye refractions) even if the outcome is only a glasses prescription.

On the flip side, when a beneficiary requests an eye examination with no specific complaint, the exam's cost is not covered even if the outcome is the discovery of a pathologic condition, Duran says.

Don't miss: Case history does not end just because the exam started, cautions Gibson. "You may not find the chief complaint until the end of the exam," he says. "Sometimes, patients forget to tell you a critical piece of history until the end of the exam."

Do you see Medicare beneficiaries who avoid needed check-ups because they fear paying out-of-pocket expenses? If so, it may be worth reviewing whether you are communicating appropriately the need for follow-up visits to every patient in your practice.

Case in point: Instead of just sending out form letters to remind all patients that it's time for their regular checkup, single out patients with identified problems by sending a different message.

Example: A patient needs to schedule an appointment for a one-year follow-up to monitor nuclear sclerosis (NS) cataracts (366.16, Nuclear sclerosis, cataracta brunescens, nuclear cataract).

Bottom line: Be sure to note in the record that the appointment is for cataract follow-up. If you follow this advice, you'll head off potential miscommunications at the front desk when a covered patient unwittingly says she is there for her "regular check-up," says Duran.

You know the golden rule of reimbursement: If it's not written in the medical record, it doesn't count. Take this lesson to heart by reminding yourself to follow these two best practices in Medicare documentation:

1. Spell out "standing orders." Medicare does not pay for undocumented "standing orders." A standing order is a policy or understanding that staff should routinely perform a particular test on certain patients even in the absence of a specific written order, says Duran.

Example: If your office has an understanding that patients with an intraocular pressure (IOP) of over 25 should automatically have an optical coherence tomography (OCT) test (92136, Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation), the physician needs to write the order in the chart.

If such notes are missing and the claim comes up for audit, you will not receive payment for this test even if you conducted it, Duran says.

2. Record test interpretations. Simply having proof that the ophthalmologist ordered and conducted some tests is not enough. In many cases, you must also take the added step of documenting your interpretation of test results, offers Duran.

You can record your interpretation with a dictated report, a notation on the progress note, or a notation on the test itself, she continues.

Example: Many physicians do not document their interpretations for fundus photography because it is "documentative" in nature, not "diagnostic," Duran notes. However, this point should not preclude you from making some type of interpretative notation in the chart, such as "photo shows increased cupping, which is consistent with elevated IOPs and visual field defect," Gibson offers.

"Record your train of thought while the case is fresh," Gibson continues. "A small detail in the photo may go unnoticed next year when reviewing the previous records unless you record the detail in the context of the exam today." You must remember to initial your interpretative notation, Duran concludes.