Ophthalmology and Optometry Coding Alert

Hint: New audits will look back at claims for the past three years.

Most eye care practices probably think their claims are under enough scrutiny as it is, but several of the recovery audit contractors (RACs) are throwing a new issue your way with additional audits focused on cataract claims.

Background: Recovery audit contractors (RACs) review Medicare claims for errors and collect a contingency fee based on the amount they recover. Much like MACs, there are different RAC contractors for the various regions in the country, and each one publishes the open issues that it is in the process of auditing.

One such issue on the plate with multiple RAC regions involves cataract removal. Regions two and three (RAC contractor Cotiviti) and Region one (RAC contractor Performant Recovery) have recently announced that they'll be reviewing the following issues involving cataract surgery:

• Cataract Removal Excessive Units – Partial Denial: "Cataract removal cannot be performed more than once on the same eye on the same date of service," Performant says in the audit review. "This query identifies overpayments where providers are billing for more than one unit of cataract removal for the same eye, on the same line of the claim."
• Cataract Removal Excessive Units – Full Denial: "CPT^® codes describing cataract extraction are mutually excusive of one another," Cotiviti says on its "Approved Issues" page. "Only one code from the affected CPT^® code range may be reported per date of service and for each eye."

The RACs posted these audit issues during the second week of March, but both are reviewing claims that go back as far as three years to find offenders. Therefore, any services that violate the cataract coding rules listed above that were submitted to payers within the last three years are subject to insurer requests for repayment.

Here's How to Avoid Problems

Essentially, these auditors are saying that you can't report multiple units of cataract removals for the same eye on the same date of service, nor can you bill multiple cataract removal codes for the same eye on the same date of service.

In black and white: Chapter 8 of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services states that cataract removal codes are mutually exclusive of each other and can only be billed once for the same eye.

"Because CPT^® codes describing cataract extraction (66830-66984) are mutually exclusive of one another, providers may not report multiple codes for the same eye even if more than one technique is used or more than one code could be applicable," CMS said in MLN Matters article SE 1319. "Only one code from this CPT^® code range may be reported for an eye."

Example: The ophthalmologist begins performing a cataract surgery in the left eye using the phacofragmentation technique (66840), but during the procedure, he has to convert the surgery to using the extracapsular technique (66940) to more easily lift the lens material. In this situation, you'll report 66940 since it's the more extensive procedure and you will not report 66840 at all.

Some practices may erroneously report both 66940 and 66840 with modifier 59 (Distinct procedural services) appended to bypass the edit, and it's possible that the insurer may pay both codes, since the CCI allows a modifier to separate this bundle. However, the reason a modifier is allowed is for cases when you perform one procedure on the left eye and the other surgery on the right eye, and in those situations, you should ideally use the LT (Left side) and RT (Right side) modifiers. An auditor who reviews a chart with both services reported for the same eye will ask for a repayment representing the amount you collected code 66840.

Resource: To read Cotiviti's audit focus, visit https://www.cotiviti.com/healthcare/who-we-serve/cms-approved-issues. For Performant's, visit https://performantrac.com/audit-regions/region-1/.