Ophthalmology and Optometry Coding Alert

Reviewers took a close look at coding ophthalmological services.

If you ever wonder where you stand in relation to other eye care practices, you are not alone. A new Comparative Billing Report (CBR) has the details to help you figure out how you compare to other practices nationwide, particularly when it comes to reporting comprehensive eye examinations.

Background: In 2018, CMS merged its CBR program with the Program for Evaluating Payment Pattern Electronic Reports (PEPPER) programs. Previously, Medicare Administrative Contractor (MAC) Palmetto GBA facilitated CBRs with its partner, consulting firm eGlobalTech. Now, RELI Group and its partners create CBRs and PEPPERs for CMS. Under this new management structure, the agency released CBR 202103 in March, homing in on claims issues with eye examination codes.

Reminder: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and health care settings. More importantly, the specialty comparisons allow Medicare providers to see how their claims match up against others in their states and across the nation in order to eradicate incorrect coding and circumvent outlier tendencies. Plus, the timely data lets you see where you stand when it comes to the frequency of billing certain services, codes, or modifiers, too.

Take a Look at the Findings

Before you consider what the findings were, it’s important to understand why reviewers examined this code set.

“Let’s take a look now at the vulnerability of correct payments for eye examinations, and how that plays into CMS’s protection of the Trust Fund,” said RELI’s Annie Barnaby during a March 15 presentation about the CBR. “The 2020 Medicare Fee-for- Service Supplemental Improper Payment Data report reflects possible improper payment rates for specific areas of coding and code sets. That report reflects a 2.3 percent improper payment rate for the ophthalmology provider type, which represents over $162 million in possible improper payments. So, we can see why this is an area of some interest when we’re looking at potential improper payments.”

She noted that when the CBR refers to “eye examinations,” it’s referring to the following codes:

• 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient)
• 92004 (…medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits)
• 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient)
• 92014 (…comprehensive, established patient, 1 or more visits)

Check out the breakdown of how eye care providers fared during the analysis.

Metric 1: Percentage of Comprehensive Eye Exams

To calculate the first metric, RELI divided the number of unique claims for comprehensive eye exams by the number of unique claims for both intermediate and comprehensive eye exams.

The national average is approximately 69 percent, Barnaby noted. However, providers in some states far exceeded that, with the highest being in Wyoming at 87.59 percent of eye care claims submitted in the comprehensive category. The lowest rate was in Puerto Rico at 34.2 percent, followed by California at 61 percent.

To determine where you stand, calculate which percentage of your eye care claims are reported with the comprehensive codes (92004 and 92014), and then compare that against your state’s average (which is in RELI’s “National and State Data” sheet at https://cbr.cbrpepper.org/About-CBR/CBR-202103) and the national average of 69 percent.

Best practice: Although CPT^® doesn't break down the levels, the AMA did cover them in the Nov. 2016 issue of CPT^® Assistant, as follows: “The comprehensive services constitute a single service entity, which does not have to be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated, biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.”

Metric 2: Average Allowed Amount Per Claim

To calculate metric 2, RELI divided the total allowed charge amount for comprehensive and intermediate eye exams by the total number of unique claims for comprehensive and intermediate eye examinations. The national average is $117, Barnaby said.

The number varied greatly by state, with Alaska coming in the highest at $146 and New Jersey second at $129.74. Puerto Rico had the lowest allowed amount at $103, followed by Arkansas at $105.

Once you determine your average allowed amount per ophthalmological services claim, compare that against the national and state averages.

Best practice: If your average amounts billed are higher than the national or state average, it doesn’t necessarily mean you’re doing anything wrong, but it can be a reason to justify taking a deeper look at your charges and billing practices. This is why it’s so important to perform a fee schedule analysis at your practice.

Metric 3: Average Number of Comprehensive Eye Exams Per Beneficiary

For the final metric, RELI divided the total number of unique claims for comprehensive eye examinations by the total number of unique beneficiaries for comprehensive eye examinations. The national average in this category is 1.28, Barnaby said.

Hawaii was the state with the highest number of comprehensive eye exams per beneficiary at 1.47, with Maryland not far behind at 1.44. Coming in with the lowest number was Iowa at 1.07, followed by Vermont at 1.09.

Best Practice: Your documentation should be impeccable if you want to back up your comprehensive eye exams, but you have to go deeper than simply listing a high number of tests to justify using the comprehensive codes. “Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry, or motor evaluation, is not applicable,” the AMA said in the Nov. 2016 issue of CPT^® Assistant. “For example, comprehensive services required for the diagnosis and treatment of a patient with symptoms that indicate a possible disease of the visual system, such as glaucoma, cataract or retinal disease, or to rule out disease of the visual system in a new or established patient.”

Double-Check Your Billing and Coding Practices

“After looking at the projected improper payment and the areas of possible error, providers should be aware that the documentation for the services is sufficient to support proper use of eye examination codes and medical necessity, and the correct code assignment for the services included in the intermediate and comprehensive code descriptions,” Barnaby said.

Resource: To read the comparative billing report, visit https://cbr.cbrpepper.org/About-CBR/CBR-202103.