Ophthalmology and Optometry Coding Alert

Don't make the same mistakes these practices did.

Ophthalmologists frequently struggle with the question of whether to report eye care codes or E/M codes when treating patients, but new data suggests that more thought should go into E/M code selection when physicians go that route.

That's the takeaway from a recent Medicare report, which states that ophthalmologists were among the 10 specialties with the highest improper payment rates for office visits. With 6.8 percent of the claims reviewed in this category classified as improper payments, ophthalmologists were responsible for over $22 million in improper payments for office visits alone.

The government's CERT auditors found other problems beyond the office visit claims. For example, ophthalmologists logged an overall Part B error rate of 3.3 percent, representing $240 million in Medicare claims. Of those improperly-paid services, ophthalmologists saw the most errors due to insufficient documentation, followed by incorrect coding, no documentation, and medical necessity errors.

The backstory: CMS issued its "2017 Medicare Fee-for-Service Supplemental Improper Payment Data" in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found a 10.2 percent improper payment rate among Part B claims during 2017, with the majority of those being classified as overpayments to providers.

Avoid These Problems With A Few Simple Tips

Keep in mind that although CMS identified 6.8 percent of ophthalmologists' office visits as improper payments, that doesn't mean that these were all overpayments. Some may have been upcoded, some may have had no documentation, while others may have been undercoded or had insufficient documentation.

To ensure that your practice isn't classified as billing and coding improperly, follow these tips to tighten up your office visit claims.

Step 1: Get to Know the Coding Levels

You may have heard that you should review all physician documentation to evaluate whether the right office visit level is being billed, but that's not necessarily the first step you should follow. If you and your ophthalmologists don't know what constitutes each service level, reviewing the documentation won't help.

Therefore, you should educate your clinicians regarding what CMS and CPT^® require for each care level. You can use the following basic guidelines for the office visit care levels as a good starting point for physician education:

E/M Codes:

New patient: Has not seen the physician, or another physician of the same specialty in the same group practice, within the past three years.

• 99201: Must include problem-focused history, problem-focused exam, and straightforward medical decision making
• 99202: Must include expanded problem-focused history, expanded problem-focused exam, and straightforward medical decision making
• 99203: Must include detailed history, detailed exam, and low-complexity medical decision making
• 99204: Must include comprehensive history, comprehensive exam, and moderate-complexity medical decision making
• 99205: Must include comprehensive history, comprehensive exam, and high-complexity medical decision making

Established patient: Has seen the physician, or another physician of the same specialty in the same group, within the past three years.

• 99211: May not require the presence of a physician
• 99212: Must have two of three: problem-focused history, problem-focused exam, or straightforward medical decision making
• 99213: Must have two of three: expanded problem-focused history, expanded problem-focused exam, or low-complexity medical decision making
• 99214: Must have two of three: detailed history, detailed exam, or moderate-complexity medical decision making
• 99215: Must have two of three: comprehensive history, comprehensive exam, or high-complexity medical decision making

Note: To help differentiate between different levels of service, see the "Instructions for Selecting a Level of E/M Service" section in the introduction to the E/M codes in the CPT^® manual.

Step 2: Don't Undercode to "Play It Safe"

If your practice routinely reports 99213 for all established patient office visits, tell your physicians that this might raise red flags with your payer. Contrary to popular belief, coding 99213 across the board will not exempt you from a government audit.

For example, a payer may identify your practice for "poor quality of care" because you consistently report low-level codes. If you submit only 99213, the payer may interpret that as saying all established patients, regardless of their conditions, receive only an expanded problem-focused history and exam. This can indicate to insurers that your physicians never take a detailed or comprehensive history or exam.

Step 3: Review Charts to Identify Problems

If your practice routinely reports the same code over and over, or if you simply suspect that you aren't coding office visits accurately, you should perform a chart review. Take a random chart sampling, and on each file you should determine the history, exam, and medical decision-making (MDM) levels, then determine which code the documentation supports.

You may be surprised what you find. "Patient feeling OK today" does not even support 99211 - but some coders have reported seeing documentation as sparse as this in physicians' notes.

Tactic:  If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table.

Optometrists Not Immune to CMS' Error Calculations

Optometry specialists were also subject to the CERT report's spotlight, and when the government listed the improper payment rate among the various specialists that bill Part B, optometrists saw a rate even higher than ophthalmologists.

The improper payment rate among optometrists for Part B claims was 5.6 percent, representing over $46 million in Part B payments. The majority of these errors (44.7 percent) were attributed to incorrect coding, while insufficient documentation came in at a close second at 41.6 percent. On the plus side, optometrists were not found to have any errors in the "no documentation" or "lacking medical necessity" categories for Part B claims. 

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2017-Medicare-FFS-Improper-Payment.pdf.