Ophthalmology and Optometry Coding Alert

Plus: Optometrists logged a nearly 90 percent DME error rate.

Eye care coders have to remember dozens of rules when it comes to the regulations for ophthalmology and optometry coding, which can be a challenge. That may be particularly true when coding for durable medical equipment, prosthetics, and orthotics (DMEPOS). A new Centers for Medicare and Medicaid (CMS) report indicates that optometrists logged the highest error rates of any specialty in this category.

Background: CMS published its “2021 Medicare Fee-for-Service Supplemental Improper Payment Data” on Dec. 7, 2021, 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 6.3 percent improper payment rate among claims submitted during the 12-month period from July 1, 2019 through June 30, 2020. The overall Part B error rate was 8.5 percent, and the overall DMEPOS error rate was 28.6 percent.

The good news is that both ophthalmologists and optometrists logged lower Part B error rates than the national average. While optometrists had a 6.4 percent error rate, ophthalmologists logged a 1.9 percent error rate. However, eye care specialists were still responsible for over $177 million in projected Part B improper payments, the agency noted. Although 2021 was certainly a year that presented new challenges, from seeing more patients via telehealth to understanding new evaluation and management (E/M) rules, physicians are expected to properly document, and physicians and coders are still expected to code and bill specialists’ services properly.

High DME Error Rate Seen Among Optometrists

Optometrists topped the list of the specialties with the most improper DMEPOS payments, with a startling 89.5 percent improper payment rate, totaling nearly $20 million in inappropriate payments.

Keep in mind: When billing for DME supplies, make sure you have the following checklist items on-hand before you report these items to your DME carrier. For example, if you’re ordering refractive lenses, you’ll need the following, according to DME MAC Noridian:

• A dispensing order, detailed written order, beneficiary authorization, and proof of delivery.
• Medical records showing that refractive lenses are necessary for vision restoration due to pseudophakia, aphakia, or congenital aphakia.
• If using anti-reflective coating, tints, or oversize lenses, the treating physician must document an individualized explanation of medical necessity in the record.
• If using lenses made of polycarbonate or other impact-resistant materials, the record must support that the patient has functional vision in just one eye.

Insufficient Documentation Among Biggest Issues for Ophthalmologists

When it came to the reasons behind ophthalmologists’ improper payments, insufficient documentation was the biggest culprit, representing 55.5 percent of the errors. Close behind was incorrect coding at 40.7 percent.

Remember that the physician’s documentation is key to supporting every code level. This may be more challenging than ever, now that practices are dealing with new E/M coding guidelines that require them to select outpatient E/M codes based on either the total time spent with the patient or the medical decision making (MDM); while selecting E/M services for inpatient, emergency department, and other places of service that still rely on the 1995 and 1997 guidelines.

“Many practices did not realize that changes to patient forms, EHR templates, and manual documentation formats needed to be reworked before the start of last year in order to best support the 2021 E/M guidelines for office and other outpatient services,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. “As a result, the support systems in place for physicians did not adequately provide what they needed to fully take advantage of the ‘Patients over Paperwork Initiative’ and best practices for documenting for the new E/M guidelines.”

Insufficient documentation doesn’t necessarily mean that your practice has lost or truncated its existing documentation — instead, it often means that the provider didn’t document enough in the first place to justify the services you billed.

Example: The physician’s documentation for an E/M service states, “Patient presented to evaluate continuing eye pain.” The record lacks a date of service, an explanation of any exam performed or history of present illness, and may also be missing many other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even the most basic information that would allow it to qualify for an office/ outpatient E/M code (99202-99215).

When it comes to incorrect coding, reviewers note this type of error when you report the wrong code for a service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter) for an office visit with a patient. The documentation demonstrates that the ophthalmologist only spent 15 minutes with the patient and that the MDM was straightforward. Therefore, the visit is downcoded to 99212 (… straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).

“Keep in mind that the new E/M guidelines are designed to pay the physicians for their cognitive work applied to the encounter,” Cobuzzi says. “But if the physician does not document their thought process — the diagnoses they are ruling out in addition to the final diagnosis, the plans of care being considered in addition to the final plan of care, and any mitigating factors such as social determinants of health or patient’s refusal to follow the physician’s advice —the auditor will not see what the physician’s cognitive work was during the encounter.” The 2021 E/M guidelines are designed for the physicians to show their work, so that whoever reviews documentation can see everything the physician was thinking and the physician can get credit for everything when determining the E/M level.

Check Which E/M Codes Featured the Most Errors

CMS breaks down which codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $722.8 million in projected improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $498.3 million in improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), Medicare made $463.9 million in projected Part B improper payments.
• New patient office visits. The new patient E/M codes (99202-99205, Office or other outpatient visit for the evaluation and management of a new patient …) were responsible for $256.1 million in improper payments.
• Hospital visit – critical care. Critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …) logged $134.8 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately, since these codes represent a major slice of your practice’s income. Particularly in light of the reimbursement losses that many eye care specialists have faced due to the COVID-19 pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0.