Ophthalmology and Optometry Coding Alert

CMS identified a total of $25.74 billion in total improper payments among providers sampled in the 2020 CERT report, and broke down those charges in a variety of categories. Check out the following explanation of how many issues the agency found in each section, and how you can avoid making the same mistakes.

Insufficient Documentation

CMS found that the vast majority of improper Medicare payments — 63.1 percent — were due to insufficient documentation. In these situations, the medical records do not substantiate whether the service was medically necessary.

Example: The documentation includes the phrase “Visit to evaluate pain around eyes after bike accident, possible fracture of orbit(s).” The record lacks a date of service, an explanation of any exam performed or history of present illness, and may also be missing many other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even basic documentation to demonstrate anything that the physician did.

Medical Necessity Errors

About 16.2 percent of improper payments outlined in the 2020 report were due to medical necessity errors. In these situations, the patient receives a service or product, but does not have a medical need for it.

Example: The patient from the orbit injury example above is seen by the physician, who orders an X-ray series (70200, Radiologic examination; orbits, complete, minimum of 4 views). Since pain alone typically does not provide the medical necessity for four views, the insurer is likely to deny this claim for a lack of medical necessity.

Incorrect Coding

About 10.9 percent of the improper payments that CMS identified were due to incorrect coding. In these situations, the wrong code was reported for the service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter) for an office visit with a patient. The documentation demonstrates that the eye care physician only spent 15 minutes with the patient and that the MDM was straightforward. Therefore, the visit is downcoded to 99212 (… straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).

No Documentation

Some 4.4 percent of improper payments were attributed to “no documentation” errors. Under these circumstances, the provider either did not document the service at all, could not find the documentation, or simply failed to submit it to reviewers.

Remember the old adage that “if it wasn’t documented, it wasn’t done” — this is how auditors will look at the situation, so you should do the same.

“Other” Errors

Issues that don’t fit into other categories, such as patient ineligibility for benefits, are classified as “other” errors, and these occurred in 5.4 percent of cases, according to the CERT report.