Ophthalmology and Optometry Coding Alert

Optometry specialists were not immune to the CERT report’s glaring spotlight, and when the government listed the improper payment rate among the various specialists that bill Part B, optometrists ranked among the most error-prone specialties.

The improper payment rate among optometrists for Part B claims was 16.5 percent, which was one of the highest rates seen in the CERT report. Only ten other specialties out of a total of 54 logged a bigger percentage of errors in their Part B claims.

What’s behind the error rate? “I think we can easily have a conversation about the lack of comprehensive coding and billing curriculum in optometry schools or the minutiae surrounding ophthalmological codes vs. E/M codes when coding encounters, or how vision plansdistort the AMA’s definition of the codes they use, but I sincerely think the higher claims error rate goes back to a lack of objective review and a lack of singular focus by the people who perform the lion’s share of the coding in optometry offices — the doctor,” says Mike M. Sandy, OD, an optometrist in Memphis who co-authored the Medical Optometric Care guide.

Because optometric practices tend to be small, autonomous units that are independently owned and have little organizational support, optometrists often wear many hats, Sandy says. “They perform clinical care, oversee the optical dispensary, and tend to be the primary administrator for the practice — includingthe billing and coding.”

This differs from large practices, which often have dedicated coding and billing staff members, he says. “When you have a person or a group of people whose primary role is to analyze exam data and code appropriately, they are emotionally removed from the patient care and can dispassionately evaluate the documentation to see if it supports the code chosen, allowing mistakes to be caught and corrected. That’s not the case in most optometric practices — my office included.”

Because Sandy’s office is a small eye care practice he is not only the doctor, but is also the first and final word in coding. “I can see a patient with a very red, swollen eye and know that I spent 15 minutes of face-to-face time and know the complete HPI and the complexity of my medical decision-making. However, if my charting doesn’t reflect that, my record becomes part of that 16.5 percent error rate. And when I have my next patient questioning my front desk staff as to why we need their supplemental insurance card and have a rep waiting to chat with me and the temperature in the office is now 84 degrees and I have an employee crying for some reason, my focus can be pulled from the chart documentation that needs to be completed to support the 99213 I’m using.”

In short, Sandy says, there may not always be one simple reason for an optometry office’s errors, but instead multiple factors. “In my opinion, I think it’s a combination of a lack of coding education for doctors, a whole other set of ophthalmological codes thrown into the mix, a lack of objective review, and a lack of singular focus. Along with Dr. Steve Nelson, I wrote Medical Optometric Care to cover the first two items. The objectivity and focus can only be controlled with systems in place and with appropriate support staff.”

Resource: To read Sandy’s guide, Medical Optometric Care, visit http://www.medicaloptometriccare.com/.