Ophthalmology and Optometry Coding Alert

Avoid key documentation mistakes that cost you pay.

Imagine if you lost 10 percent of your ophthalmology practice’s collections — you’d be in big trouble. Well, that’s the error rate CMS found in the latest Comprehensive Error Rate Testing (CERT) results, and your MAC may come looking for money you still owe them.

Possibility: CMS also noted in the report that it still owes $1.4 billion to providers who were underpaid in 2013 — so consider that a refund might be coming your way.

Either way, read on to leverage the report findings into a how-to lesson for avoiding future claims errors.

Get Familiar With CERT Report

To create the CERT report, CMS reviewed 48,227 claims, including Part B, Part A, and DME, according to the “Medicare Fee-for-Service 2013 Improper Payment Report.” Auditors then pored over the claims to determine which had no documentation, insufficient documentation, incorrect coding, or reflected a medically unnecessary service.

Errors: Part B practices demonstrated a 10.5 percent error rate overall, with incorrect coding accounting for 0.7 percent of the errors. Not all of these errors reflected overpayments to practices — in some cases, doctors actually shorted themselves by coding incorrectly.

Documentation: Insufficient documentation accounted for 1.7 percent of the errors in the CERT report. But the most vexing single problem of all is the number of providers who can’t produce any documentation at all, according to additional CERT findings published in the October 2014 Medicare Quarterly Provider Compliance Newsletter.

Common problem: CERT auditors may ask a provider for an item that’s missing from the documentation and receive a response that includes the exact same records they already have. If you find yourself in this situation, don’t try and save time by resubmitting the same documentation again. Instead, take the time to find the missing information and get it to the auditor as soon as possible so you won’t have to repay the MAC.

Recognize E/M Errors

Are you interested in avoiding the most common culprits that led to such a high Part B error rate? Then you should nail down your E/M claims going forward.

CMS found that providers improperly billed $3.9 billion in E/M claims, resulting in a 13.4 percent improper E/M payment rate. If you want to avoid that type of error — which will most certainly result in auditors requesting refunds — double-check your E/M level. “Incorrect coding and insufficient documentation caused most of the improper payments for E/M services during the 2013 report period,” the CERT report states.

Often, the errors were due to practices submitting documentation that supported a different E/M level than what was billed. Other issues included insufficient documentation, no physician authentication, or wrong place of service.

Do this:“If you are performing regular compliance audits for correct coding, then errors of incorrect E/M codes will be less likely,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel. “It is also important to audit notes for the medical necessity of the level of service claimed,” he says.

Split/shared services:The CERT auditors also found a large number of errors when reviewing split/shared E/M services. “Split E/M services occur when the physician and a qualified NPP each do a substantive part of an E/M visit face-to-face with the same beneficiary on the same date of service,” the report states. “A physician can only bill this visit under his or her NPI for certain E/M visits and settings. Insufficient documentation causes most of the improper payments for these claims.”

Bottom line: If you’re called for an audit, you should pull all encounters that have been selected for audit with all of the accompanying documentation, and double-check that everything required is in each file. If you find any issues while preparing your records for audit, do not alter documentation, change billing records, destroy records, or in any other way compromise the information. You may want to contact your practice’s attorney for advice on how to present the missing information to the auditor.