Ophthalmology and Optometry Coding Alert

Can't seem to get your ophthalmologist to document thoroughly? The latest CERT report results might help refocus your practice's attention on proper documentation very quickly.

According to the most recent Comprehensive Error Rate Testing (CERT) results, Medicare requested $9.3 billion in reimbursement back from practices that lacked complete documentation, and your practice may have been one of them.

The new CERT results, which reported data from claims submitted to Medicare between Oct. 1, 2006, and Sept. 30, 2007, were released May 16.

Upside: The new report wasn't all bad news, however. Despite an improper-payment tally of $10.2 billion (including both overpayments and nearly $1 billion in underpayments), the error rate dropped to just 3.4 percent, a small fraction of the whopping 14 percent error rate that CMS found in 1996.

CMS counted more than $785 million in errors for practices that were missing documentation, and $1.3 billion in deficient documentation. The figure becomes even worse when you hear just what types of deficiency errors CMS discovered.

"The fact that the error rate has dropped is great news," says Jay Neal, a consultant in Atlanta. "But an error rate of over $10 billion is still high."

Ophthalmologists had a 1.9 percent error rate in paid claims, leading to $86,993,842 in projected improper payments. By comparison, occupational therapists logged an astounding 21.2 percent error rate, and neurosurgeons weren't far behind with an error rate of 15.3 percent.

Watch for: If your practice is submitting 99211, beware. A new CMS report reveals that more than 15 percent of claims submitted to Part B for this code last year were missing critical documentation, causing Medicare to request more than $20 million back.

The CERT report found 99211 (Outpatient E/M that may not require a physician) billed inappropriately across the board, both in the "insufficient documentation" and "no documentation" categories.

"Practices may be surprised by this high error rate because many people think it doesn't take comprehensive documentation to report 99211," says Heather Corcoran with CGH Billing. "But that's probably the exact reason it's billed in error so often -- practitioners assume because it's a low-level code, they don't have to document very much information, which is wrong. Thorough documentation is necessary no matter how much money you'll collect for a particular code."

Additionally, the medical record must provide documentation to support medical necessity for the E/M service. This is true for all E/M and procedural services, including 99211.