Ophthalmology and Optometry Coding Alert

Learn how a simple fax can keep you compliant with documentation rules

Now's the time to review how you document your ophthalmologist's consults--before the feds come and start investigating your files.

Consults look like a juicy target to fraud-busters in the wake of a new report by the HHS Office of Inspector General that found 75 percent of consults (99241-99245, Office consultation for a new or established patient ...) didn't meet Medicare requirements. Only one-third of the dollars billed in 2001, $1.1 billion out of $3.3 billion, were incorrect, but that's still a high price tag.

Here are the problems:
 
• Nearly half of all consults (47 percent) were coded as the wrong type of consult or at an incorrect level, accounting for $613 million in consult billings. In particular, 41 percent of consults were upcoded and 5 percent were downcoded, the OIG says. One-third of upcoded services were upcoded by two levels (e.g., a level-three office consultation, 99243, mistakenly coded as a level-five consultation, 99245), and 10 percent were upcoded by three levels.
 
• One in five consults (19 percent) didn't meet Medicare's definition of a consult and should have been coded as a regular E/M visit, adding up to $191 million in incorrect billings. Most of these visits "were actually lower-paying regular office or inpatient visits," the OIG says. Providers also tried to bill psychiatric diagnostic interviews or discharge management services as initial inpatient consultations. Also, two consults were provided by nurses, who aren't eligible to bill for them.

• Nearly one in 10 consults (9 percent) didn't have enough documentation to justify billing a consult, and this cost Medicare $260 million. Reviewers found no documentation in the patient's medical record, including records from the consulting physician, the requesting physician and the facility.

• Almost all consults billed at the highest level (95 percent) were coded incorrectly, the OIG says. On average, these were upcoded by 1.9 levels, meaning almost all of these level-five consults should have been level-three instead.

The recommendations: Medicare should educate physicians about how to code for consults, the OIG says. This education should include determining the appropriate level of consultation service to report, documentation of the consultative request and report of findings and recommendations to the requesting physician. Secure Documentation With This Resource Medicare issued Transmittal 788, dated Dec. 20, 2005, with an implementation date of Jan. 17, 2006, to provide consultation policy clarifications regarding the definition, documentation requirements, when and by whom a consultation may be performed/reported, a split/shared evaluation and management service, and nonphysician practitioners.

Key: Both the provider performing the consultation and the provider requesting the consultation must document the consultation request and reason in the patient's medical record, the transmittal states. One way to ensure that requests for all [...]