Ophthalmology and Optometry Coding Alert

Coders and physicians who want to avoid fraud or other criminal charges would be wise to read the new 2004 Work Plan from the Office of the Inspector General.
 
The plan, which outlines aspects of Medicare and Medicaid billing that will be scrutinized for fraud and misuse, was announced on Oct. 1.
 
Briefly, here are the highlights:

Consultations
 
The OIG will be looking into the appropriateness of billings for consultations. Two billion dollars was allotted for consults in 2000.
 
The OIG plans to "determine the appropriateness of billings for physician consultation services and the financial impact of any inaccurate billings on the Medicare program. In addition, we will determine the primary reasons for any inappropriate billings."

Coding of E/M Services
 
The inspectors will assess the adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level E/M codes.
 
Twenty-three billion dollars was spent on E/M in 2001. They plan to "assess the adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level evaluation and management codes that result in greater Medicare reimbursement."

Use of Modifier -25
 
The use of modifier -25 accounted for $1.7 billion of the $23 billion in reimbursement for E/M codes in 2001. The OIG will determine if the claims were billed and reimbursed appropriately.

Use of Modifiers With NCCI Edits
 
In 2001, $565 million was paid to providers who used modifiers to unbundle code pairs. The OIG will determine if modifiers were used appropriately. The report states that the 'initiative, one of CMS' tools for detecting and correcting improper billing, is designed to provide Medicare Part B carriers with code pair edits for use in reviewing claims. A provider may include a modifier to allow payment for both services within the code pair under certain circumstances."
 
The entire report is available online at the department of Health and Human Services Web Site at http://oig.hhs.gov/publications/workplan.html#1.