Ophthalmology and Optometry Coding Alert

And learn from these OIG settlements.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has recently hit ophthalmology hard with investigations, and they are not done yet, according to Rhonda Buckholtz, CPC, CDEO, CPMA, CRC, CENTC, CGSC, COBGC, COPC, CPEDC, AAPC Approved Instructor, chief compliance officer at Vision Innovation Partners in her “Risk Management Ophthalmology” presentation at HEALTHCON 2024.

Some highlights in Buckholtz’ presentation included explaining the key risk areas in ophthalmology, recent investigations, what to look for when auditing, and aiming for quality in risk adjustment audits.

Identify Areas of Ophthalmology Risk

Ophthalmology coding and billing is under heavy scrutiny. Buckholtz said that she works on many risk adjustment audits and Medicare Targeted Probe and Educate (TPE) program audits for cataract surgery, as well as .

Other areas of heavy scrutiny are:

• Medicare-based patients (elderly population)
• High-cost/high-volume surgical procedures
• Retina injections with high dollar drugs
• Co-management for post operative work
• Kickbacks for referrals
• Cash upgrades or markups for lenses

Risk management can help ensure that your ophthalmology practice is compliant with relevant laws and regulations that are being audited to help avoid legal issues and potential penalties.

Recent Investigations Reveal OIG Targets

In the HEALTHCON presentation Buckholtz discussed recent million-dollar ophthalmology OIG investigations and settlements, including:

• $2.9 million settlement – This was a whistleblower case in which Arlington Ophthalmology Associates, P.L.L.C. (d.b.a. Kleiman Evangelista Eye Centers, “K&E”) resolved allegations of offering and paying kickbacks to optometrists for cataract surgery candidate referrals in violation of the False Claims Act and Anti-Kickback Statute.
• $1 million settlement – An optometry and ophthalmology provider with 24 facilities, Barnet Dulaney Perkins Eye Center, PC (BDP) allegedly required disabled patients who needed wheelchair transfer assistance for surgery to use and pay for third-party medical transport, and some were denied eye surgery outright, in violation of the Americans with Disabilities Act (ADA). For the settlement, the defendants will train staff on non-discriminating policies for patients with mobility issues and offer safe transfer techniques. They will pay a civil penalty of $50,000 and $950,000 to the patients and prospective patients who were harmed by their policies.
• $5.7 million settlement – The government alleges that Massachusetts Eye and Ear compensated 44 physicians in a way that violated the Physician Self-Referral Law (Stark Law). Massachusetts Eye and Ear allegedly entered into improper financial arrangements with referrals and paid more than market value for physician services to boost profits.

This settlement shows that there needs to be no favoritism with physician gifts. “Everything needs to be fair market value, especially when handling outside co-management — It has to be equitable. If we’re giving small gifts to outside doctors for Christmas or other holidays or those types of things, we need to be giving the same monetary value to the one who refers the least as the one who refers the most,” Buckholtz noted.

These ophthalmology cases are important because the government clearly spells out what is expected and the need for compliance and auditing.

Include Comanagement in Risk Management Audits

It’s important to perform audits to prevent financial penalties and take backs and to ensure quality reporting. Here is what Buckholtz said you should be looking for in your audits:

• The consent for comanagement form, which needs to be signed by the outside Doctor of Optometry (OD) prior to a patient being transferred. This helps to avoid double billing, and nothing should be billed until you get the consent for comanagement.
• The transfer of care form, which must have dates that correspond to when the patient was seen and when the care transferred from surgeon to the outside OD, not when the OD first saw the patient. Additionally, the language in the agreement needs to be specific
• Evidence of an investigation into special OD relationships with friends, relatives, roommates, and so on, which would preclude comanagement
• Documentation indicating co-management/transfer of care was the patient’s choice.
• Documentation of activities of daily living (ADLs) to support medical necessity for cataract surgery.

During audits, make sure the following are also clearly documented in the medical record: the patient’s condition, medical necessity for the services provided, vendor relationships, drug/lot number, prior authorization for injections, and the visits with injections.

“You need to make sure that you’re checking all the boxes before those claims go out the door,” Buckholtz said. “Same with your surgeries: you need to make sure you have everything before you bill for those.”

Quality Diagnosis Reporting Is Key

Buckholtz also talked about risk adjustment auditing and the impact on compliance, the Merit-based Incentive Payment System (MIPS), and a practice’s revenue cycle, which is “really impacting us and killing us in ophthalmology,” Buckholtz believed.

Ophthalmology gets hit hard with risk adjustment, Buckholtz explained, because they have Medicare patients with such conditions as diabetes, cataracts, retinopathy, and macular edema. Those are all Hierarchical Condition Category (HCC) risk adjustment codes, meaning you should be document underlying comorbid conditions and counsel for risk adjustment purposes. You should also look to ICD-10 guidelines and “with or without” rules for “cause and effect” relationships for certain conditions. Last, you should speak to your physicians about capturing all the codes with the correct causal relationship verbiage, and always query your physician when documentation is questionable or not clear.

Buckholtz emphasized, “Quality should be part of your compliance plan!”

Michelle A. Dick, BS, AAPC