Ophthalmology and Optometry Coding Alert

Avoid the fate of this optometrist, who must pay over $3 million back to Medicare.

Have you ever wondered whether your unusually unique code submissions could catch auditors’ attention? If you thought that was just an urban myth, think again One optometrist learned that lesson the hard way this fall and agreed to pay $3.2 million back to Medicare to settle allegations of fraud after the government flagged him for being a statistical outlier based on his claim submissions. After further investigating the optometrist’s charts, the government found that the physician billed for the following medically unnecessary services:

• Punctal plug insertions
• Sensorimotor testing
• Vision therapy/orthoptics
• Amniotic membrane placement

Not only did some of the patients not need these services at all, the government alleged, but in some cases, the optometrist was said to have performed the services repeatedly on the same patient more often than what would have been reasonable, according to U.S. Attorney Ryan K. Patrick in a Sept. 29, 2020 news alert on the case.

Keep in mind that billing a statistically higher volume of a particular code doesn’t necessarily mean you’re at risk of having to pay money back, but it does mean you’re inviting scrutiny. To ensure that you aren’t running afoul of the law and that you can pass any audit with flying colors, prove medical necessity for the services you perform with this advice.

Check Necessity for Punctal Plug Insertions

The physician in question was said to have performed and billed for medically unnecessary punctal plug insertions (68761, Closure of the lacrimal punctum; by plug, each), which eye care specialists typically perform to treat dry eyes. However, before you take that step, many payers want you to try other therapies, such artificial tears. Generally, those more conservative therapies would not be separately billable, and you would instead include them in an E/M (99202-99215) or eye exam (92002-92014) CPT^® codes.

If you do ask the patient to try lubrication drops prior to considering punctal plugs, make sure that’s noted in the patient’s record, along with any of your payer’s other requirements. For instance, Aetna states in its policy that was updated in July 2020, “Aetna considers punctal plugs, standard punctoplasty by electrodessication or electrocautery medically necessary for members with severe dry eyes that are not adequately treated by conservative interventions including a 2 or more week trial of artificial tears, ophthalmic cyclosporine (Restasis) where indicated, and adjustment to medications that may contribute to dry eye syndrome.”

In addition, Aetna notes, the patient must have a diagnosis of severe dry eyes (which could be noted using terms such as dry eye syndrome, keratoconjunctivitis sicca, xerophthalmia, xerosis, or sicca syndrome), which is reflected in the chart notes “with documented objective evidence of lacrimal gland deficiency (e.g., Schirmer test or the tear break-up time test) or evidence of corneal decompensation on slit-lamp exam (i.e., an ocular surface dye staining pattern (rose bengal, fluorescein, or lissamine green) characteristic of dry eye syndrome).”

If your documentation is missing any of these items, chances are that your punctal plug insertion would be considered medically unnecessary. Of course, not all payers follow the same guidelines, and you must know each insurer’s requirements before billing for this service.

Check These Guidelines for Sensorimotor Testing, Vision Therapy

Also on the optometrist’s hit list were inappropriate billing of sensorimotor testing (92060, Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)) and vision therapy (92065, Orthoptic and/or pleoptic training, with continuing medical direction and evaluation).

Most insurers have strict frequency guidelines for reporting these services. For instance, Oxford Health Plan’s policy states, “One diagnostic evaluation (CPT^® 92060) is payable regardless of diagnosis. Orthoptic/Pleoptic therapy is covered for members based on the following recommended guidelines: Two therapeutic/follow-up therapy visits (CPT^® 92065) on a yearly basis for the care of convergence insufficiency as indicated by diagnosis code billed.”

Other insurers have different frequency guidelines, such as a limit of 12 units of 92065 for Aetna. In addition, you’ll have to meet specific diagnosis requirements to report any of these codes, and those diagnoses must be reflected in the medical record.

Amniotic Membrane Placement Requires Specific Diagnoses

The final service that the government said was billed inappropriately by the optometrist was amniotic membrane replacement, which is typically reported with 65778 (Placement of amniotic membrane on the ocular surface; without sutures), 65779 (Placement of amniotic membrane on the ocular surface; single layer, sutured), or 65780 (Ocular surface reconstruction; amniotic membrane transplantation, multiple layers). Due to state scope of service laws, optometrists typically report 65778, says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York.

These services are fairly uncommon and are typically only covered under extreme circumstances, such as neurotrophic keratitis “with ocular surface damage and inflammation that does not respond to conservative therapy,” according to Blue Cross Blue Shield of Massachusetts’ policy. Those conservative therapies can include such options as five days of pressure patching, therapeutic contact lenses, topical lubricants, and topical antibiotics. The policy lists several other conditions that can justify payment for amniotic membrane replacement, and you must be laser focused on ensuring that your documentation includes one of them, along with notes about previous conservative treatments, to collect for the service.

If you don’t document thoroughly, you’re likely to have to pay back your reimbursement for this procedure, which is hefty — about $1,436 in the non-facility setting for 65778.

Bottom line: Being an outlier on a coding bell curve isn’t an indication that you’ve committed fraud, but doing so without documentation to back up the medical necessity of your services will surely land you in hot water. If your documentation isn’t up to par, it’s time to sit down with your providers and show them what sufficient documentation looks like, letting them know how much money they could lose if they don’t start documenting thoroughly.

Resource: To read the Department of Justice’s news alert about the case, visit www.justice.gov/usao-sdtx/pr/laredo-eye-doctor-pays-over-3m-resolve-fraud-claims.