Optometry Coding & Billing Alert

Published on Tue Oct 04, 2016 PDF

Determine whether you can accurately code this eye care chart.

 Would the partners at your optometry practice be okay with a nearly 15 percent error rate among your reimbursements?

Chances are, the answer is a firm no. But that was the average error rate among Part B E/M services according to CMS’s latest Comprehensive Error Rate Testing (CERT) report, which discusses the biggest drivers of Medicare errors. E/M services logged a 14.6 percent error rate last year, totaling some $4.6 billion in wrongful payments, according to the latest report, which was released on Sept. 12.

To ensure that your eye care practice isn’t among the offenders, take some time to brush up on your E/M skills. Check out the following E/M note and determine what the physician did right, and what he could have improved upon.

Code reported: 99201

Chief complaint: Bilateral eye pain.

HPI: This 66-year-old female patient complains of bilateral aching, sharp eye pain that has been of moderate severity for the past four weeks. It is most severe in the evenings before she goes to bed, and is especially painful when she has watched television or sent emails on her computer. Nothing seems to help, including closing her eyes or taking Tylenol. She does not complain of floaters, watering, or ophthalmic migraines.

PMFSH: The patient has had no previous eye issues and has never had surgery, but she did have a sinus infection last year and has high cholesterol. Her mother died of melanoma and her father died of congestive heart failure. She is a retired teacher and swims occasionally but does not practice another exercise regimen. She has no allergies to food or medications. She takes a multi-vitamin every morning and Lipitor but is on no other medication. She does not wear prescription glasses but occasionally wears her husband’s reading glasses in the evening to look at the newspaper.

ROS: Patient reports no orbital pain and has no swelling around the eyes. She reports no changes in vision and no discharge from her eyes.

Physical Exam

Constitutional: Healthy-appearing and NAD.

Psychiatric/Neurological: Patient is pleasant with positive orientation to time, place, and person.

Eyes: Sclera appear white. Gaze is normal and motility normal. Conjunctiva are pink and smooth, with the bulbar conjunctiva not showing evidence of capillaries outside normal limits. No edema of the lacrimal gland. Cornea appears healthy on slit lamp exam, with tear film and epithelium normal, anterior chamber depth 3.0 mm, PERRLA. Pressures are 20 mmHg. Extraocular motility and alignment normal in both eyes.

Assessment/Plan: Discussed with the patient the fact that she may have eye strain due to using her husband’s reading glasses (which are too strong for her), then watching television or using the computer. Although her eyes do not appear dry today, I explained to her that they may get that way at the end of the day, particularly if she is focused on the TV or computer. Prescribed +1.50 reading glasses in both eyes and preservative-free eye lubricant drops if her eyes are uncomfortable while watching television.

Did You Spot the Problems?

Unfortunately, this chart was undercoded for this new patient since the chart qualifies for reporting 99202. This resulted in the practice shortchanging itself to the tune of $31.00 (99201 pays about $44 and 99202 reimburses approximately $75).

The review of systems (ROS) in this case has one organ system reviewed (eyes), which makes the ROS pertinent and the overall history level expanded problem-focused, creating an expanded problem-focused history, detailed exam and low MDM which makes this a 99202. 

Although $31.00 may not sound like a lot to throw out the window, consider the fact that coding just three of these visits a week incorrectly adds up to almost $5,000 per year.

Resource: To read the complete CERT report, which includes the detailed error rate results, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2015_Improper_Payments_Report.pdf.