The OIG report headline, released Dec. 23, 2014, read Medicare Paid $22 Million in 2012 for Potentially Inappropriate Ophthalmology Claims. While that sentence seems daunting, it actually represents a fraction of the approximately $8.2 billion Medicare paid ophthalmologists in 2012 to “screen for, diagnose, evaluate, or treat cataracts, wet age-related macular degeneration, and glaucoma.”

Medicare Administrative Contractors (MACs) are held responsible for many of the inappropriate payments due to poor oversight of their own Local Coverage Determinations (LCDs).

For example: The number and dollar amount of claims paid beyond each of the limitations established in LCDs for 2012 reporting includes:

Wet AMD

Medicare paid approximately $2.2 billion in 2012 for services associated with the diagnosis of wet AMD. Excessive testing for wet AMD as determined by MAC LCDs:

• CPT code 92235 Fluorescein angiography is not allowed more than four times per eye per year for some MACs and up to 9 times per year for others.
• Some LCDs stipulate CPT code 92250 Fundus photography is not allowed more than two times per eye per year.
• CPT codes 92235 Fluorescein angiography and 92240 Indocyaine-green angiography are not allowed within 30 days of one another on the same eye, unless performed on the same day or unless the patient has a second diagnosis in addition to wet AMD. However, the second diagnosis cannot be diabetic retinopathy. Frequency edits are not to exceed 9 times per eye per year for some LCDs.
• CPT codes 92133 Posterior segment imaging (glaucoma) and 92134 Posterior segment imaging (retina) are not allowed on the same day for the same eye for all payers.
• CPT code 92134 Posterior segment imaging (retina) is not allowed more than once a month according to some LCDs.
• A few LCDs state CPT codes 92225 Extended ophthalmoscopy and 92226 Subsequent ophthalmoscopy are not allowed more than 12 times per eye per year combined.
• HCPCS code J2778 Lucentis is not allowed more often than every 28 days per the package insert instructions.

Cataracts

Medicare paid approximately $3.5 billion in 2012 for exams that “screen for, diagnose, evaluate, or treat cataracts.”

• There is a national requirement which states that, “Medicare will not routinely cover more than one comprehensive eye examination and scan for patients whose only diagnosis is cataract.”
• MACs erroneously paid 10,560 times for more than one cataract surgery per eye in the same year.

Glaucoma

Approximately $1.3 billion in 2012 was paid by Medicare to screen, diagnosis, evaluate and treat glaucoma.

• Glaucoma screening tests billed for patients who had already been screened within the past 12 months.

Note: The report is data driven only. No actual patient records were reviewed. However, MACs may now choose to take further action by recouping inappropriate payments.

Resources

• The entire OIG report can be downloaded from the HHS website.