Ophthalmology and Optometry Coding Alert

Plus: Ophthalmologists suffered from upcoding errors.

No one has ever said that coding for eye care is easy – and that seems to have been proven by CMS’ most recent report, which documents millions in errors by optometrists and ophthalmologists.

Background: CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 8.1 percent improper payment rate among Part B claims during 2018.

Optometrists Logged Startling DME Error Rate

Optometrists topped the list of the specialties with the most improper DMEPOS payments, with a startling 92.3 percent improper payment rate, totaling over $18 million in inappropriate payments. The majority of those errors (66.1 percent) were due to insufficient documentation, while another 3.7 percent occurred because of medical necessity errors, and the remaining 1.8 percent stemmed from no documentation at all.

If you’re an optometry practice reporting things like post-cataract excision glasses and contacts to your DME supplier, keep the following tips in mind, which are from DME Medicare Administrative Contractor CGS Administrators:

• For beneficiaries who are aphakic and do not have an IOL, replacement lenses are covered by most DME policies when they are medically necessary.
• Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating physician. UV protection is considered reasonable and necessary following cataract extraction; therefore, additional medical necessity justification by the treating physician beyond inclusion on the order is not necessary.
• The addition of UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary.
• Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to an aphakic beneficiary, will be denied as not reasonable and necessary.
• Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are covered.

In addition, you’ll want to make sure you have the following checklist items on-hand before you report these items to your DME. These are from DME MAC Noridian:

• A dispensing order, detailed written order, beneficiary authorization, and proof of delivery
• Medical records showing that refractive lenses are necessary for vision restoration due to pseudophakia, aphakia, or congenital aphakia
• If using anti-reflective coating, tints, or oversize lenses, the treating physician must document an individualized explanation of medical necessity in the record
• If using lenses made of polycarbonate or other impact-resistant materials, the record must support that the patient has functional vision in just one eye
• Use the KX modifier if you report V2750, V2744, V2745, V2780, or V2784, but only if the items meet the medical necessity criteria, advises Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology in Canandaigua, New York. “Never use the modifier just to get the claim paid,” she says.

Ophthalmologists Appear to Be Upcoding

When it came to ophthalmologists, these specialists were called out for having a high number of upcoding errors, collecting over $9 million for upcoded claims.

If you aren’t familiar with the term “upcoding,” it refers to reporting a higher code than your documentation justifies. For example, suppose you report 92014 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits) but the documentation doesn’t support the fact that the physician performed a comprehensive service including a complete visual exam.

In this case, it’s likely that your payer will say you upcoded the claim and you should have reported 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) instead.

Therefore, you should always familiarize yourself with the coding requirements for each level and ensure that the documentation supports every code you’re reporting. Frequent upcoding not only causes accusations of compliance issues, but also requires you to pay back the reimbursement you were overpaid.

Don’t Ignore CERT Requests

Reading about the CERT results may prompt you to wonder what you’d do if the government requested your records as part of a CERT audit. You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. Take a look at Hanna’s advice and other expert tips on CERT correspondence:

Fax: This is the preferred method, Hanna says. “Always include the barcode sheet as part of your fax package. This simply marries the documentation you’re submitting with that particular date of service the CERT contractor has chosen for a review.”

• esMD: The electronic submission of medical documentation system (esMD) is another option. With this method, you use the gateway you contracted with and follow standard procedure.
• Postal Mail: “If it’s a sizeable amount of documen­tation, or you’ve already saved it to a CD, you can mail it in,” Hanna adds. If you send a CD, it can only contain TIFFs or PDFs and should be encrypted in line with HIPAA Security Rule standards, according to CERT Review contractor AdvanceMed.
• Email: You may send an encrypted email, but “if [it’s] encrypted, the password and CID# must be provided” with a follow-up phone call or fax, advises AdvanceMed.

Don’t miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor grants extensions only in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

“But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension,” Hanna acknowledges. “If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights.”

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to repay the money, Hanna cautions.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuple­mentalImproperPaymentData.pdf.