Ophthalmology and Optometry Coding Alert

Self-audits can help you catch these issues early.

When your ophthalmologist performs surgical procedures, how often do you review the operative notes and ensure that the code the physician wants to report is accurate? As a coder, it’s in your scope of work to ensure that claims are being reported accurately, and you just might be surprised at what you see.

In some cases, physicians erroneously report the wrong codes by accident, but in others, reviewers might suggest that the physicians are doing so deliberately. Such is the case with one New York eye care practice, where the government filed a federal indictment in November accusing the ophthalmologist of fraudulently billing patients, Medicare, and private payers. Over the course of seven years, the physician allegedly overbilled millions for complex eye procedures that the government says he did not actually perform.

In addition, the practice is accused of upcoding procedures, tests, and exams that were billed to Medicaid and Medicare. On top of that, the government says, the physician pressured his staff members to falsify patient medical records and launched debt collection proceedings against patients who didn’t pay for the fraudulently billed charges.

Coders: Check the Codes Your Practice Is Submitting

Coders should typically be cross-checking 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 cause your office to be reactive by refiling claims, rather than proactive in finding problems before you submit the claims.

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.

Check for Accuracy

When you review the charts, ask yourself whether the billed codes are supported by the documentation. For example, if a 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…) is coded for a new patient, make sure the key components of comprehensive history (including a review of systems) and comprehensive examination and a moderate complexity of medical decision-making are documented.

Keep in mind that just because documentation supports the level of service billed, the coder or biller must be sure that it’s medically necessary to report that level of service, says Gina Vanderwall, OCS, CPC, CPPM, financial counselor with Finger Lakes Ophthalmology of Canandaigua, New York. “One can have excellent documentation that supports a higher level of service, but medical necessity must be taken into consideration as well. You can’t always bill the higher level of service simply because your documentation has all the bullet points checked,” she adds.

If an office visit and a procedure are coded, does the documentation support both? Was time a factor in coding the service? In the cases in which counseling and/or coordination of care dominate more than 50 percent of an encounter, time also is considered a key controlling factor in qualifying the visit for a particular level of E/M service, but you must ensure that the documentation supports time-based billing.

Finally, make sure that the diagnosis codes on the billing form are supported by what actually appears in the record.

Your office should take note of any claims that were billed inaccurately during these self-audits, and should educate the physicians if anything looks off-base.