Optometry Coding & Billing Alert

Audit alert: If your billing pattern differs too much from Medicare statistics, you could be sending up a red flag

If you-re not keeping track of your code use, you should, because CMS certainly is. The agency keeps track of how often optometrists report certain E/M codes -- and if you vary from the pattern too much, it may want to know why.

Medicare recently released its utilization statistics for Part B services that it paid in 2006, with information provided for each specialty. Here's how optometrists used the office visit E/M codes in calendar year 2006:

Source: "Medicare Part B Physician/Supplier National Data, Calendar Year 2006, Evaluation and Management Codes by Specialty."

In all, Medicare paid optometrists for 2,626,881 office visits in 2006. Nationally, 99213 was the code all specialties billed most frequently -- Medicare paid practices for the code more than 1 million times overall.

Look at the allowed services for each office visit code as a percentage of the total, and compare them with your own practice's data:

Although the rates might vary in different locations, this data would lead Medicare to expect approximately 5 percent of your E/M visits to be 99203 and 42 percent 99213, for example.

If you find your own billing statistics to be much different from this bell curve, you may want to make sure you-re not habitually coding level-three established patient E/M services as level-four services.

Remember: To report 99214, you must document at least two of the following: a detailed history, a detailed exam, and medical decision-making (MDM) of at least moderate complexity. You also need to be sure that the nature of the presenting problem and medical necessity support coding a level four.

Many coding consultants recommend not selecting an established patient E/M code level above that supported by the MDM level. "It's difficult to justify a 99214 for a simple pressure check or a follow-up visit for an uncomplicated problem," says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

Pitfall: Some insurers raise red flags when a practice only reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that level.

Bottom line: Choose your E/M code based on your documentation every time, and your coding will naturally reflect the optometrist's range of services.

Do this: Download national billing statistics from http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp.