Ophthalmology and Optometry Coding Alert

Question: On two occasions within the past few months, our billing department submitted claims through insurance companies for two surgeries using the wrong codes. The surgeries actually should have been billed using a higher RVU code because both cases were complicated and another code better described the procedure. I have already been paid on both claims. Should I just let this go, or is it acceptable practice to resubmit the billing for these surgeries with the proper code and return the fees from the original bill?

Maryland Subscriber

Answer: You should rebill using the proper codes. Mistakes happen, and you need to bill correctly. You can send a "corrected claim" with a short letter explaining that the new submission is not a duplicate, but corrected coding and billing. Write "corrected claim" across the bottom of the claim.

Consequences: If you get audited, you could be fined for undercoding as well as overcoding. During an audit, undercoding and overcoding can both be deemed fraudulent billing, so you should always correct errors.

Best bet: Send documentation to support these corrected codes so the carrier will pay the new claim correctly and timely. Depending on your carrier, you may have to return the entire original reimbursed amount back to the carrier for reprocessing for the additional payment. Other payers will just send you the difference.

Suggestion: You may also want to call the patient and simply explain what happened so that if he receives additional communications about the surgery from his payer, he won't think your office is trying to charge twice.

Inform the patient that you are sending a corrected claim to the insurance carrier and that he should be expecting an extra explanation of benefits (EOB) from the insurance company showing that it reprocessed the claim using the correct procedure codes.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla.