Ophthalmology and Optometry Coding Alert

Avoid his mistakes to ensure you don't get caught in the government's crosshairs.

Overbilling medications and reporting bilateral codes for unilateral services may seem like simple mistakes, but for one ophthalmologist, doing those and other things repeatedly led to a guilty verdict, and he could face up to 30 years in prison for it.

Solomon Melgen, MD, was convicted of health care fraud for his part in a scheme that defrauded over $100 million from the Medicare program. The Florida-based ophthalmologist brought in more money from Medicare than any other physician in the US for most of the years between 2008 and 2013, said Assistant US Attorney Roger Stefin during Melgen's sentencing hearing.

Among the accusations against Melgen were claims that he billed bilateral tests for all patients, even those who had one prosthetic eye, ABC News reported. In addition, Melgen was said to have spent just seconds performing tests that should have taken longer, and although he was not able to use them diagnostically, he still billed Medicare for up to 100 patients daily for the services.

Also at issue was the accusation that Melgen split single-use vials of Lucentis into four separate doses and billed the government per-dose even though he didn't open separate vials of the drug, which resulted in him collecting four times the amount he should have for the drug. Not only was he billing fraudulently, the government opined, but he was also exposing patients to potential eye infections due to the increased risk from splitting the vials.

Stay on the Straight and Narrow With These Tips

You can avoid Melgen's fate by ensuring that you're coding these services properly. When you report Lucentis injections using the indicated single dose, 0.5 mg, you should report five units of J2778 (Injection, ranibizumab, 0.1 mg). On the same claim, report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug. Most insurers will accept a code from the H35.32xx (Exudative age-related macular degeneration) series to prove medical necessity for an intravitreal Lucentis injection.

If your provider injects both eyes, report 67028 with modifier 50 (Bilateral procedure), or with modifiers LT (Left side) and RT (Right side).

Therefore, if you inject 0.5 mg of Lucentis into the patient's left eye to treat exudative age-related macular degeneration, you'd report 67028-LT, J2778 x 5, and H35.3220 (Exudative age-related macular degeneration, left eye, stage unspecified).

Unilateral services: As noted above, Melgen was said to have reported bilateral services, even when patients only had one eye. To avoid operating this way, you must get to know which codes are inherently bilateral. For example, Medicare considers 92250 (Fundus photography with interpretation and report) to be inherently bilateral. In other words, the payer bases its reimbursement on the procedure being performed on both eyes.

Don't miss:  If the ophthalmologist only photographs one eye, modifier 52 (Reduced services) may be your best bet, say experts. You can then append modifier LT (Left eye) or RT (Right eye) to specify which eye was photographed, although those modifiers are informational and do not affect reimbursement.