Ophthalmology and Optometry Coding Alert

Report: Optometrists log more DME coding errors than any other specialty.

Keeping track of all the coding rules specific to ophthalmology and optometry can be endlessly challenging. And apparently, chief among the challenges is coding for durable medical equipment, prosthetics, and orthotics (DMEPOS), since a new CMS report indicates that optometrists logged the highest error rates in reporting these services.

Background: CMS issued its “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 18 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 8.6 percent improper payment rate among Part B claims submitted between 2017 and 2018.

The improper payment rate for DMEPOS claims among optometrists was 74.2 percent. Although this ranked at the top of the list for problematic claims in this category, it was almost a 20 percentage point decrease from last year, when optometrists saw 92.3 percent of their DMEPOS claims billed in error.

Of these claims, 74.5 percent were deemed improper payments due to insufficient documentation, while another 3.8 percent had no documentation at all.

Ophthalmologists Among Specialties With Most Part B Improper Payments

When it came to the specialties that brought in the highest value in improper payments, internal medicine ranked the highest, with over $1.1 billion projected in improper payments. While internal medicine practitioners logged a 13.5 percent improper payment rate, ophthalmologists fared better, with an improper payment rate of 4.8 percent. That totaled over $293 million, making ophthalmology the specialty with the seventh highest value of improper payments.

Among the issues that CMS discovered when reviewing ophthalmologists’ Part B claims was a problem with upcoding. These specialists logged $4.7 million in Part B upcoding errors, the report noted.

Although there isn’t just one reason that causes practices to code higher than the documentation supports, it’s important to remember that the physician’s documentation is key to supporting every code level, says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. “We often have to remind the physicians to document their thought process in the course section of their electronic medical record,” she says. “The ‘risk’ of presenting problem or potential illness/injury does factor into the medical decision making,” 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.”

Initial Hospital Care Logs High Error Rate

Topping the overall list of E/M services with improperly paid claims was 99223 (Initial hospital care, per day, for the evaluation and management of a patient…), which is the highest level of initial hospital care. Far exceeding the national average for improperly paid claims, this code saw an error rate of 24.1 percent. This led to about $433 million in improper payments over the past year.

Chief among the issues with 99223 was incorrect coding, which represented about 80 percent of the improper charges for the service. Coming in a close second was insufficient documentation, which was responsible for about 17.5 percent of the improper payments.

When it came to outpatient codes, 99214 (Office or other outpatient visit for the evaluation and management of an established patient…) hit the top of the list, generating about $423 million in improper charges, driven by incorrect coding in 67 percent of cases and insufficient documentation in 28 percent of them.

Resource: To read the full CERT document, visit cms.hhs.gov/cert and click “CERT Reports” on the left side of the page. From there, you can download the 2019 report.