Ophthalmology and Optometry Coding Alert

Remember: Even an unsigned visit note can cost you over $300.

Just because you’re getting paid for your retinal photocoagulation claims doesn’t mean you’re documenting them correctly. In fact, if the latest Medicare Quarterly Provider Compliance Newsletter, released on Jan. 31, is any indication, most ophthalmologists could use a primer on how to report these services.

Does Your File Include All the Notes?

CMS scrutinized claims for 67228 (Treatment of extensive or progressive retinopathy, [e.g., diabetic retinopathy], photocoagulation) and found that most improper payments for this service were due to insufficient documentation. This is a broad category, but can include everything from missing test results to no documentation supporting medical necessity for the service.

For example: One ophthalmologist submitted a bill for 67228, but when asked for documentation to support the claim, the doctor only sent an unsigned office visit note showing bilateral diabetic retinopathy, a plan for pan-retinal laser photocoagulation (PRP), and notes from bilateral posterior segment examination. The doctor also submitted an unsigned operative note for the billed date of service, documenting PRP of the left eye.

“The submitted documentation was insufficient to support the medical necessity for the PRP since the documentation submitted was unsigned,” CMS says in the Compliance Newsletter. “Medicare requires that services provided/ordered be authenticated by the author. This claim was scored as an insufficient documentation error and the payment was recouped from the provider.”

The cost: Since Medicare pays between about $310 and $350 for 67228, the doctor had to forfeit that much for the service. If you report just one of these a month without having the documentation to support it, you’ve just lost $4,200 a year — simply due to lacking medical records.

Consider These Documentation Best Practices

To ensure that you aren’t forced to send back reimbursement to your carrier, check out the following documentation tips from healthcare consultant Terri Orcala of Orcala Billing in Kansas City, Mo.:

Progress notes should be complete. When the physician sees the patient for her initial appointment, the doctor can’t skimp on a full description of what he saw — otherwise, you might lack documentation of medical necessity for the procedure itself, Orcala says. “The ophthalmologist might have great documentation of the procedure, but if he doesn’t show why he did it, you won’t get paid. A lot of those ‘why’ questions can be answered by looking at previous office visit notes, which show what was going on that required the surgery.”

Signatures are essential. Even the most thorough note in the world means nothing if the doctor doesn’t add his John Hancock at the end, Orcala says. “I see this way more often than you’d think,” Orcala says. “It’s hard to imagine that a claim isn’t payable just due to that simple signature oversight, but it happens a lot.” 

Ensure that notes are legible.  This problem has largely been corrected due to the use of EHRs, but there are still physicians that write notes in the records, and if those notes aren’t legible, then they aren’t useable in an audit, Orcala says. “Use this standard: If people in your office can’t tell what the doctor wrote, then an auditor wouldn’t be able to figure it out. Any doctor with messy handwriting should be transitioned to an EHRandif they tend to write additional notes, get them a dictation system,” she advises.

Resource: To read the entire Compliance Newsletter, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909313.pdf.

Check This Sample Documentation for 67228

If you aren’t sure whether your notes for 67228 are up to snuff, consider the following sample note for a retinal photocoagulation treatment:

Mrs. Jones presents for retinal photocoagulation today due to OS diabetic retinopathy.

Patient was appropriately prepped and anesthetized. I measured her visual acuity and dilated the patient’s pupil. Using a slit lamp delivery system after applying a fundus contact lens to the globe, ablated to the mid-peripheral and peripheral retina via laser. After confirming that the target vessels were appropriately coagulated and necrotized, the patient was advised of appropriate post-procedure ophthalmic care and asked to return in three days.