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March 2007

Savvy Coder: Coding & Reimbursement
How to Prevent Costly Coding Errors: Three Audits and 10 Lessons Learned
By John Haley, MD, OCS, Stephen A. Kamenetzky, MD, OCS,
and Sue Icchrilli, COT, OCS

When Drs. X and Y went through the mill of a Medicare audit, they both emerged wiser but poorer. And a self-audit at Dr. Z’s practice uncovered serious problems, too. Here are 10 lessons that can be learned from their mistakes.

Dr. X—the billing situation. Whenever Dr. X coded 92014 Eye code established comprehensive exam, his staff person, who was not trained in ophthalmology, switched it to 99214 Level 4 E&M established patient before submitting the claim.

Audit. Medicare requested 35 records for claims coded as 99214, and Dr. X denied using that code. He failed the audit and all 35 charts were downcoded to 99213 Level 3 E&M established patient.

Dollars lost. Even before the audit, the practice had lost $455 on those 35 records because the staff person had switched each one from 92014 ($96 allowable) to 99214 ($83). The audit caused a further loss of $1,050 because each record was downcoded from 99214 ($83) to 99213 ($53). Furthermore, Dr. X could expect another audit within three to six months to assure compliance.

Lessons to be learned from the audit:
Staff should not change a code without consulting the physician who is ultimately responsible for it.
#2. Review procedure productivity reports by physician each month or quarter.
#3. Physicians and staff, including whoever processes EOMBs, should be properly trained.


Dr. Y—the billing situation. Although Dr. Y routinely performed functional blepharoplasties, she didn’t know the specific criteria for surgery because she had never gone to her Medicare payer’s Web site for the appropriate Local Coverage Determination (LCD).

Audit. Ten blepharoplasty cases were audited. Two cases did not qualify as functional, but instead were cosmetic. Furthermore, Dr. Y hadn’t obtained an advance beneficiary notice (ABN) from the patient.

Dollars lost. In each case the practice had billed Medicare for 15823–RT ($600) and 15823–LT ($300 after a 50 percent reduction for being the second procedure), so it had to refund a total of $1,800 for the two cosmetic surgeries. Without an ABN and associated –GA modifier, Dr. Z can’t bill the patient and instead operated for free.

Lessons to be learned from the audit:
Know the LCDs.
#5. Know when to obtain an ABN.
#6. Remember when to use –GA.


Dr. Z—the billing situation. Dr. Z’s practice documented 66170 Fistulization of sclera for glaucoma, trabeculectomy ab externo in absence of previous surgery, at the time of 66984 Cataract with IOL. The claim was submitted as 66984–LT ($654); 66170–59–51–LT ($452 after a 50 percent reduction for being the second procedure). Total payment was $1,106. Modifier –59 was appended to unbundle the procedures according to the version of CCI the office was using (7.0).

Audit. The practice’s new billing manager performed a retrospective billing audit and discovered three problems. First, Dr. Z hadn’t marked or approved the code that staff selected on the superbill. Second, modifier –59 was used incorrectly; the two procedures aren’t bundled according to the version of CCI (12.2) that was actually in effect at the time of surgery. Finally, the trabeculectomy has higher RVUs than cataract does, which is significant because the practice only received 50 percent of the allowable for the code that was submitted second.

Dollars lost. The practice would have received an extra $125 if it had submitted the codes in this order: 66170–LT ($904); 66984–51–LT ($327 after a 50 percent reduction) for a total payment of $1,231.

Lessons to be learned from the audit:
Have a fee schedule or RVUs for all procedures billed. When billing, list the codes in order of highest to lowest allowable.
#8. Use the current version of CCI.
#9. Apply modifiers properly. Know when and when not to use modifier –59.
#10. Physicians should mark or routinely evaluate how the superbill is filled out.