Ophthalmology and Optometry Coding Alert

Question: How concerned should we be about medical record reviews by the Centers for Medicare & Medicaid Services (CMS) since the COVID-19 public health emergency (PHE) is still ongoing and may be extended through the end of the year?

New Jersey Subscriber

Answer: Stay vigilant. While CMS put many investigations and reviews on pause during the pandemic, medical reviews have picked back up.

Some experts say that the agency may be looking at medical records of Medicare parts A and B beneficiaries through additional development requests (ADRs) and Targeted Probe and Educate (TPE) programs for a rationale to support skilled services. If any errors are identified, Medicare Administrative Contractors (MACs) will work with you and help you correct them.

Many common mistakes are simple — such as a missing signature — and easily fixed. Frequently encountered claim errors include:

• Documentation does not meet medical necessity
• Encounter notes do not support all elements of eligibility
• Missing or incomplete initial certifications or recertification
• The signature of the certifying physician was not included

“This summer brought an increase in both SMRC [supplemental medical review contractor] and TPE audits,” adds Mary Pat Johnson, CPC, CPMA, COE, COMT, senior consultant with Corcoran Consulting Group. “In ophthalmology, the attention was focused on cataract surgeries, glaucoma procedures, and intravitreal injections.”

Remember: CMS works with Medicare contractors for claims processing and other administrative functions. Therefore, your respective MAC may be a key connection point in assisting CMS with local claims, as well as reviewing the first level of appeals adjudication functions.

For more information on medical reviews go to www.cms.gov/ Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review.