Ophthalmology and Optometry Coding Alert

Plus, how to keep your 66982 claims squeaky clean.

In 2017, the spotlight may be on your ophthalmology practice. Can you withstand scrutiny? Check out these potential errors and tips to keep your claims picture perfect.

Heads up: More and more MACs are conducting pre-payment reviews of claims, said expert coder Jennifer Edgar, OCS recently at AAO’s annual conference.

Measure Your Claims Against These Documentation Pitfalls

On their pre-payment review radar are four kinds of documentation errors that could land your ophthalmology practice in hot water before you even get paid, Edgar said:

1. No evidence of patient’s Best Corrected Snellen Visual Acuity (BCVA) present in the record.
2. No evidence of patient-reported impairment of visual function resulting in restriction of activities of daily living.
3. Absence of a signed operative note or report.
4. Lack of documentation indicating the patient desires surgical correction, has received explanation of risks/benefits/alternatives, and that the expected outcome will significantly improve visual and functional status.

These four points of documentation are necessary for ALL cataract surgeries to support medical necessity — and additional documentation is needed to support an anticipated complex cataract surgery.

Don’t Be Timid About Complex Cataract Claims

Potential error: It’s been more than year since HHS OIG released a study saying that many ophthalmology practices were improperly upcoding cataract claims as “complex” and submitting 66982. But providers may have over-corrected for this upcoding, Edgar and Sue Vicchrilli, COT, OCS told AAO attendees.

Over the past year, some coders have been reluctant to bill 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [1- stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification], complex, requiring devices or techniques not generally used in routine cataract surgery [e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis] or performed on patients in the amblyogenic developmental stage) — even when the code is appropriate.

Since the OIG released its report, “the American Academy of Ophthalmic Executives has received many questions about how to correctly document and bill for complex cataract surgery,” Edgar and Vicchrilli wrote in their recent AAO article “Coding Complex Cataract Surgery With Confidence.” But shying away from 66982 even when it’s warranted could mean missing out on hard-earned revenue.

What to do: The key, as always, is to support your code choice with the proper documentation. Edgar and Vicchrilli recommend asking these four questions to help you determine if a cataract case is actually complex, or if you’re in dangerous upcoding territory:

1. Does the pupil require dilation manually or using special instruments?
2. Does the IOL need the support of a capsular tension ring or intraocular sutures?
3. Is this a pediatrics case that includes IOL implantation?
4. Does the cataract require dye (like Trypan Blue or Indocyanine Green)?

Check Out This Example of Upcoding

Scenario: Some practices make a habit of coding every cataract surgery where dye was used to stain the capsule as “complex.” But the use of dye doesn’t always meet 66982’s requirements. Sometimes it’s just an additional surgical step. Some other examples of procedures that aren’t necessarily “complex” include:

• A case that takes longer than usual (i.e. if more phaco time is required)
• Many cases that require an anterior vitrectomy (planned or unplanned)
• Implantation of a toric or multifocal lens, as opposed to a standard one

Here’s What Qualifies as Complex

The following kinds of surgeries are more likely to be “complex,” Edgar and Vicchrilli said:

• The majority of pediatric cases
• A case that requires manual dilation of the pupil
• A case requiring implantation of a capsular tension ring

Of course, your surgeon’s op report should clearly state the reasons why the surgery qualifies as complex, but the best way to indicate complexity on your claim is to use the appropriate ICD-10 code(s). Medicare LCDs list a variety of diagnosis codes that justify 66982, so check with your local MAC for the most up-to-date specifics.

According to AAO, “in order to indicate why the surgery qualifies as complex, you must also report one of the following codes …” in addition to the traditional cataract diagnosis. Note that some payers will require two or more ICD-10 codes.

Editor’s Note: To read the OIG’s 2016 report, “Questionable Billing for Medicare Ophthalmology Services,” go to https://oig.hhs.gov/oei/reports/oei-04-12-00280.asp.