Ophthalmology and Optometry Coding Alert

CMS says optometrists logged startling 84 percent DME error rate.

Eye care coders have to remember dozens of rules when it comes to the regulations for ophthalmology and optometry coding, which can be a challenge. That may be particularly true when coding for durable medical equipment, prosthetics, and orthotics (DMEPOS), because a new CMS report indicates that optometrists logged the highest error rates in this category.

Background: CMS issued its “2020 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 21 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 a 2.3 percent improper payment rate for ophthalmologists and a 6.9 percent improper payment rate for optometrists among Part B claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

The good news is that both ophthalmologists and optometrists logged lower Part B error rates than the national average, which came in at 8.1 percent. However, eye care specialists were responsible for over $228 million in projected Part B improper payments, the agency noted.

Optometrists Logged High DME Error Rate

Optometrists topped the list of the specialties with the most improper DMEPOS payments, with a startling 83.5 percent improper payment rate, totaling over $15 million in inappropriate payments. The majority of those errors (58.5 percent) were due to insufficient documentation, while another 1.8 percent stemmed from no documentation at all, and 39.6 percent were attributed to “other” issues.

Best practices: When billing for DME supplies, you’ll want to make sure you have the following checklist items on-hand before you report these items to your DME carrier. For example, if you’re ordering refractive lenses, you’ll need to have specific details on hand, such as the following, 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.

Insufficient Documentation Among Biggest Issues for Ophthalmologists

Upcoding was an issue for ophthalmologists, with cataract removals/lens insertions on the list of the most frequently upcoded services. But when it came to the reasons behind ophthalmologists’ overall improper payments, insufficient documentation was the biggest culprit, representing almost 77 percent of the errors. Close behind was incorrect coding at over 23 percent.

Remembering that the physician’s documentation is key to supporting every code level is essential, says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. This may be more challenging than ever now that practices are dealing with new E/M coding guidelines that require them to select outpatient E/M codes based on either the total time spent with the patient or the medical decision making (MDM).

“We often have to remind the physicians to document their thought process within the encounter of their electronic medical record,” Tamez says. “The ‘risk’ of presenting problem or potential illness/injury does factor into the MDM,” she adds.

In addition, Tamez notes, you must document the differential diagnoses that the physician considers which require additional workup or treatment. “This helps the coders know if this patient has a potential high-risk problem,” she adds. “Remember, the chart reviewer cannot assume why you ordered certain tests. Coders cannot interpret, infer, or imply why any treatment or tests are ordered.”

Check Which E/M Codes Featured the Most Errors

CMS breaks down which codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $400.9 million in projected improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), Medicare made $359.5 million in projected Part B improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $261.6 million in improper payments.
• New patient office visits. Coming in fourth on the list, the new patient E/M codes (99202-99205, Office or other outpatient visit for the evaluation and management of a new patient …) were responsible for $260.6 million in improper payments.
• Hospital visit – critical care. The fifth code series with incorrect coding error involved critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …), logging $146.1 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately, since these codes represent a major slice of your practice’s income. Particularly in light of the reimbursement losses that many physicians are facing due to the pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit www.cms.gov/restricted-access-vbdlvcertreportsdl/2020-medicare-fee-service-supplemental-improper-payment-data.