Ophthalmology and Optometry Coding Alert

Coders: Always cross-check codes billed against the documentation.

When your ophthalmologist bills for procedures you don’t see reflected in the documentation, do you bring it to the physician’s attention? One New York medical practice may not have been taking this step, and the ophthalmologist is now under fire from the US government.

Here’s why: In September, an ophthalmologist in Rye, New York, pled guilty to his part in a seven-year fraud scheme in which he was accused of falsely billing for procedures he didn’t perform to the tune of millions of dollars. “He grossly overbilled minor ophthalmological procedures, billed for tests and procedures that were never performed, falsified medical records, attempted to corrupt others in his practice to abet the scheme, and sent patients who refused to pay his fraudulent charges to collections,” said US Attorney Audrey Strauss in a statement about the doctor’s guilty plea.

Read on to understand how you can ensure that you don’t find our practice in the crosshairs of these types of investigations.

Cross-Check Codes

Coders should always cross-check any codes billed against the documentation. If it isn’t in the record, you cannot report the services. In this case, the offending doctor would have easily been discovered if the practice had performed semiannual audits, so ensure that your practice is on an appropriate audit schedule to catch any such issues.

You can either perform a prospective audit (in which your practice examines new claims before you file them) or a retrospective audit (when your practice examines paid claims). A prospective audit helps you identify and correct problems before sending the claim, which could mean you’ll discover incorrect coding or charges that would otherwise have been missed. Keep in mind that this type of chart audit can potentially delay billing, however.

Retrospective chart audits do not delay billing, but causes your office to be reactive by refiling claims, rather than proactive in finding problems before you submit the claim.

Best bet: Your practice must determine for itself what types of audits your staff can reasonably complete and what effects on claim submission timing and cash flow the practice can handle.

What to Do After a Self-Audit

After completing your self-audit, the next step is to identify key problem areas and eliminate them by training physicians and billers. You’ll first sift through your findings and identify issues and trends, and then set up time to meet with the staff members, either as a group or individually. During your feedback sessions, you might consider using the following steps to help better illuminate the issues you discovered.

1. Use visual aids to illustrate problems. Generating an E/M bell-curve chart for each provider and comparing it to their specialty-specific national-average curve is helpful because you can easily identify any overcoding or undercoding and know which codes to address with each physician. In addition, showing a provider their coding mistakes in such an easy-to-read format will help convince them the problems are real and require their attention and cooperation to fix.

2. Organize education and feedback sessions. If your internal audit identifies erroneous coding patterns, you should use case notes from the audit to guide education and feedback. If several providers and billers need training on the same topics, you may want to arrange a group training session. Individual sessions are better for providers or billers who have unique coding problems, or who require more attention.

Strategy: Suppose one of your providers is consistently reporting level-two established patient visits when they should be using level-three codes. Your first step should be to show the provider their personal billing bell-curve chart so they can clearly see the undercoding. Make sure they understand the results of their specific audit and recognize that they need an education session. Arrange a time when you can sit down together and review the principles of E/M coding and how they can apply these to their typical patient visits.

For example, you can go through the documentation for a few of the provider’s audited E/M claims and explain why the provider selected the wrong level. They may have underdocumented the patient’s history, risk factors, ordered tests, or the plan of care. Another audit-revealed problem area could be that the provider is using nonspecific diagnosis codes when the documentation indicated more specific codes.

You should also give providers a takeaway tool that will help remind them of key billing elements. In this situation, a checklist of necessary elements to select the appropriate E/M code would be appropriate.

Follow-up: Education is very important, and feedback is essential. Remember to check on your providers’ documentation and coding routinely and tell them when they improve. In addition, you should arrange a problem-focused audit and at least one formal feedback session several weeks after the training to assess the providers’ progress and give any additional pointers or recommendations.

Always: Be sure the provider or biller you’re training has a clear understanding of why they must change their billing behavior. If undercoding is the problem, stress the fact that the practice is losing deserved reimbursement because of these mistakes. If overcoding is the problem, remind them that compliance is a must to keep the practice out of legal hot water.

3. Conduct another audit. Sometime after your post-audit compliance session, you should reaudit the problem areas revealed during the first audit. You may want to just focus on the problem providers whom you trained. Consult your compliance plan for specifics on when and how you should follow up on an audit that reveals problems.

Reaudit and retest your providers and billers at given intervals to ensure no one is backsliding. Individuals learn at different paces, so consistency in the audit/education cycle is what will eventually produce results.

Last resort: If some providers persist in noncompliant coding, you need to consider corrective actions. Consult your compliance plan to see if specific guidelines dictate how you must handle a chronically noncompliant physician. If you don’t have a compliance plan, you need to have some guidelines in writing to dictate your actions in this situation.