Ophthalmology and Optometry Coding Alert

Overcoding and undercoding contributed to more than $17 million in projected improper Medicare payments in 2008, according to the most recent Comprehensive Error Rate Testing (CERT) results. You can prevent errors and plug revenue sinkholes to guarantee your practice's correct reimbursement using these leveling guidelines:

Undercoding takes place when a practice bills a level of service at a level lower than what the patient's history, examination, and decision making support, says Carla Mack, OD, Director of Clinics at the Ohio State University College of Optometry in Columbus. A practice may record and bill a level-two established patient E/M visit (99212, Office or other outpatient visit for the evaluation and management of an established patient ...) when the patient history, examination, and decision making support an E/M level three (99213).

Example: An established patient presents with a red, irritated right eye after repeatedly sleeping in a soft contact lens not approved for extended wear. An expanded problem-focused history, expanded problem-focused examination, and low complexity decision making are appropriately documented in the medical record and support the patient's primary complaint of a red, painful eye.

The visit should be coded as an established E/M level three (99213); however, the ophthalmologist bills the encounter as a level two (99212). Undercoding by one E/M level will result in a loss of approximately $24 per visit under the 2009 Medicare Physician Fee Schedule.

Alternative: Better yet, bill 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient), suggests David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. "If you have all the history and testing to bill 99213, you should have enough to bill 92012," he says.

You don't have to reserve 92012 for a complete eye exam. Be aware, however, that some general medical (non-Medicare plans) place limits on the number of times a year the 92000 codes can be billed, especially if the 92012 code is used for routine care.

Code 99212 is the lowest level visit that requires the doctor's presence with the patient. Ophthalmology coders often use the code when they are following up a previously diagnosed case. The level of service is too low to make a new or additional diagnosis or change a treatment plan, Gibson notes. It is generally the best code when following up a resolving non-complicated case.

Overcoding is the inverse of undercoding and happens when a problem-focused E/M office visit is coded at a higher level than what the patient history, examination, and decision making support.

Example: In the previous case, if the ophthalmologist documented a problem-focused history, a problem-focused examination, and straightforward medical decision making, 99212 would be the appropriate code. Billing 99213 instead would lead to an overpayment of approximately $24, which the payer may ask you to pay back if a chart reviewer determines that documentation does not support the level of service billed.

Another key area of concern is providing proper recording or documentation the service performed. This is pivotal in determining if your practice will get its correct reimbursement.

"In most of these coding situations, we found that the level of service had been performed, but not appropriately documented or in some cases, documented at all," said Mack. "If you take a history or perform testing and don't record it, it is as if you never performed it at all."

Aside from office visit and evaluation, there are a number of ophthalmic procedures that are billable separately, including:

• 76514 -- Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

• 92020 -- Gonioscopy (separate procedure)

• 92083 -- Visual field examination, unilateral or bilateral, with interpretation and report; extended examination ...

• 92135 -- Scanning computerized ophthalmic diagnostic imaging, posterior segment (e.g., scanning laser) with interpretation and report, unilateral

• 92250 -- Fundus photography with interpretation and report

• 92285 -- External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereophotography).

Discovering the most common coding and billing errors is the first step to correcting them, says Mack. "The staff, doctors and interns should understand the importance of correct coding as it relates to practice management and the overall value of the services that we provide."