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January 2007

Savvy Coder: Coding & Reimbursement

10 Activities That the OIG Plans to Investigate in 2007
By Sue Vicchrilli, COT, OCS, Academy Coding Executive and
David A. Durfee, MD, Senior Secretary for Ophthalmic Practice

The Office of Inspector General’s work plan for 2007 raises questions about more than 500 programs and activities. The 10 activities most relevant to Eye M.D.s are as follows.

  1. Evaluation of “incident to” services: When staff provide Medicare services that are “incident to” the professional services of physicians, are those staff services appropriate and medically necessary? To qualify as “incident to,” services must be part of the patient’s normal course of treatment during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician need not be physically present in the exam room, but must be present in the office suite. In ophthalmology, the focus will be on “the tech code,” CPT 99211. Previous OIG investigations resulted in 99211 being bundled with special ophthalmic testing service codes. (For more on 99211, see the November/December, 2002, Savvy Coder at

  2. Eye surgeries: When Medicare is billed for services related to cataract and LASIK eye surgery, does the billing meet Medicare requirements? And when carriers process those claims, do their procedures prevent inappropriate payments? The OIG might look into documentation and coding for cataract and complex cataract surgery, for presbyopia-correcting IOLs and for new technology IOLs. And when physicians correct astigmatism that the patient was born with, including correction by LASIK, are they inappropriately using CPT codes that are meant for surgically induced astigmatism (65772–65775)?

  3. E&M services and global surgery periods: Are physicians receiving inappropriate, separate payments for E&M services provided during the global surgery period? And has the global surgery fee concept affected the number of services that are provided during the global surgery period? (The idea behind the global surgery fee is that one fee is billed for all services that are usually associated with the surgical procedure. Modifier –24 is only meant for services unrelated to the surgery.)

  4. Balance billing: To what extent are Medicare providers billing beneficiaries more than the regulations allow? Providers must accept Medicare’s payment and the beneficiary copayment as full payment for all covered services.

  5. Botox treatments: Are they always reasonable and necessary? Medicare’s Botox coverage includes specific conditions associated with certain diagnoses that are medically necessary. In most states, Local Carrier Determinations address documentation and coding.

  6. Use of modifiers KS, KX and ZX for durable medical equipment claims: Does the documentation support medical necessity? This issue might arise, for instance, when physicians indicate that it is medically necessary for a patient to have tinted, antireflective or oversize lenses, and modifier –KX is applied.

  7. Place of service errors: Are physicians properly coding the place of service on claims for services provided in ASCs and hospital outpatient departments? The physician fee schedule often pays a site-of-service differential.

  8. Billing service companies: What relationships exist between billing companies and the Medicare providers who use their services? Do those arrangements impact the providers’ billing?

  9. Physician pathology services: What relationships exist between doctors who furnish such services and outside pathology companies? Are doctors compliant with Medicare Part B?

  10. Services provided by physical and occupational therapists: Are their vision rehabilitation services being adequately documented?