Ophthalmology and Optometry Coding Alert

Ophthalmologists need to know the key factors in deciding when it is appropriate to co-manage a patient in order to avoid fraud. Its a common scenario: A patient goes to an optometrist for routine care, the optometrist sends the patient to an ophthalmologist for cataract treatment, then the ophthalmologist sends the patient back to the optometrist for postoperative care. This is an example of co-management, which requires the modifiers -54 (surgical care only) and -55 (postoperative management only). But its not as simple as it sounds. The Office of the Inspector General (OIG) of the Department of Health and Human Services reviews these cases to make sure that the surgeon is not giving the postoperative services to the optometrist in exchange for referrals for surgery.

Follow Societies Guidelines

The key point to remember is that the patients interest, and not the economic interest of the physicians, must come first, according to a joint position paper released in February 2000 by the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS).

When modifiers -54 and -55 are used, it means that 80 percent of the fee goes to the surgeon and 20 percent goes to the postoperative physicianproviding that the optometrist provides postoperative care for the full 90 days in the case of a cataract operation. Ophthalmologists have been concerned about potentially abusive referral arrangements with optometrists who wish to receive the postoperative portion of the Medicare global fee for eye surgery, the Nov. 19, 1999 Federal Register notes in commentary to a rule regarding safe harbors. The ophthalmologists allege that many optometrists refer patients to ophthalmologists on the condition that patients be referred back to the optometrists for post-
surgical care, often without regard to clinical appropriateness, the commentary says. One commentary described a situation where an optometrist/ophthalmologist network referred patients for cataract surgery only to ophthalmologists who would agree to split the global surgical fee by referring the patient back to the optometrist for postoperative care. The optometrist referred their patients to an ophthalmological surgery center 200 miles away when there were at least 50 available ophthalmologists from 7 to 35 miles away.

In response, Medicare modified the scope of its safe- harbor rule, to preclude protection for arrangements between parties that share or split a global or bundled payment from a federal healthcare program for the referred patient.

While co-management is interpreted by different carriers with variations of restrictions, the American Medical Association (AMA) and the American College of Surgeons has issued guidelines stating that the operating surgeon has the responsibility for the postoperative care. Co-management is not approved by these societies if economic considerations drive the decision to transfer the care of a patient following surgery, the position statement says. Although this obligation may be ethically ceded to another healthcare provider, it is anticipated that this will be an exceptional, rather than a routine, occurrence. If the reasons for sharing postoperative care with another provider, however well trained, are economic, specifically as an inducement for surgical referrals, or the result of coercion by the referring practitioner, it is patently unethical and, in many jurisdictions, illegal, the position paper says.

The OIG is concerned that optometrist-ophthalmologist co-management takes place based on economic considerations (i.e., to benefit the provider) rather than for clinical reasons (i.e., to benefit the patient). Therefore, the OIG has refused to provide safe-harbor protections for such arrangements, preferring to review cases on an individual basis. The revision specifically denies safe- harbor protection for referral arrangements where the parties bill Medicare using the -54/-55 modifiers to indicate an 80-percent/20-percent split of the surgical fee for cataract surgery. Does this mean all referral arrangements involving splitting fees are illegal? No. But it does mean that the legality will be decided on a case-by-case basis.

When Its OK to Co-manage

When should you decide to co-manage a case? According to the AAO/ASCRS position paper, you should rely on justifiable circumstances, such as the surgeons unavailability due to travel, illness, leave, itinerant surgery in a rural area, or surgery performed in a designated physician shortage area.

Co-managing a case is also acceptable if the patient cannot travel to the surgeons office because of distance or the development of another illness.

Correctly Co-managing

When the ophthalmologist decides that it is in the patients best interest to delegate postoperative care to the optometrist, here are some of the guidelines that the AAO and ASCRS recommend:

The ophthalmologist must inform the patient, before surgery, if there are any postoperative management plans, and the patient must consent to these plans in writing. Document the consent in the medical record, including the reason for the transfer of care, the qualifications of the optometrist, and any risks that may result.

If the transfer of postoperative care is unanticipated, inform the patient and document this in the medical record.

The ophthalmologist should tell the patient what the financial implications from the co-management arrangement are, particularly in terms of the patients payment obligations and the optometrists reimbursement.

There should be no transfer of care unless clinically appropriate and in the best interests of the patient.

The ophthalmologist should confirm that the optometrist is professionally trained to perform he services.

Co-management should not be done routinely on all patients.

The ophthalmologist should keep following the patient until the patient is stable; there can be no fixed time when the patient is sent back to the optometrist.

The patient must be told that he or she has access to the ophthalmologist during the postoperative period at no additional cost.

Note that if a Medicare patient returns to the ophthalmologist because a problem develops, the surgeon would end up seeing the patient for no additional compensation, explains Lise Roberts, vice president of Health Care Compliance Strategies, Syosset, N.Y. Medicare carriers do not allow the post-op portion of a global package to be split more than once, she says. Once the care has been transferred, the receiving provider bills the remainder of the postop care days and the carrier will not make adjustments after that.

It is important for ophthalmologists to avoid what the AAO refers to as the coercive use of the -54/-55 modifiers.This is the scenario: The optometrist asks the ophthalmologist before referring a patient, Do you share post-op care? If the answer is no, says Roberts, then the referral isnt made. The optometrist calls around until he or she finds an ophthalmologist willing to send the post-op care back. I have heard of situations where the optometrist referrals stopped almost overnight when the ophthalmologist refused to send the patient back for post-op, she says.