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January 2008

Savvy Coder: Coding & Reimbursement
What You Need to Know About the OIG’s Work Plan for 2008
By Sue Vicchrilli, COT, OCS, Academy Coding Executive and David A. Durfee, MD, Senior Secretary for Ophthalmic Practice

Each year, the Office of Inspector General (OIG) publishes a list of activities that it intends to investigate. In its latest work plan—which you can read online at—the category of Medicare Physicians and Other Health Professionals includes several topics that you should know about.

Place-of-service errors. Federal regulations provide for different levels of payments to physicians depending on where the services are performed. Medicare pays physicians a higher amount if a service is performed in a nonfacility setting, such as a physician’s office, than it does if the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center (ASC). The OIG will review whether physicians are properly coding place-of-service on claims for services performed in ASCs and hospital outpatient departments.

Evaluation and Management (E&M) services during the global surgery periods. Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure, as well as related E&M services provided during the global surgical period. Unrelated E&M services rendered during the global period are payable by appending modifier –24 to the exam. Typically the diagnosis code is also unrelated to the surgery. The OIG will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee.

Medicare payments for selected physician services. The OIG will review the appropriateness of Medicare payments for various types of physician services to determine whether these services were paid in accordance with Medicare requirements. (The OIG work plan didn’t include any further details.)

Medicare “incident to” services. Once again, the OIG will review Medicare claims for services furnished “incident to” the professional services of selected physicians. These services are typically performed by a nonphysician staff member in the physician’s office and are coded with CPT code 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. The OIG study will review medical necessity, documentation and quality of care for “incident to” services. (For more on such services, see October’s EyeNet at

Assignment rules by Medicare providers. Providers are not allowed to balance bill the patient for amounts in excess of the Medicare allowable. The OIG will determine the extent to which providers may be doing that.

Geographic areas with high utilization of ultrasound services. The OIG will focus on areas in the United States with disproportionately high Medicare allowed charges and services per beneficiary. It will target CPT codes such as:

  • 76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter
  • 76511 quantitative A-scan only
  • 76512 B-scan (with or without superimposed nonquantitative A-scan)
  • 76513 anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy
  • 76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness)
  • 76516 Ophthalmic biometry by ultrasound echography, A-scan;
  • 76519 with intraocular lens power calculation
  • 76529 Ophthalmic ultrasonic foreign body localization

2008 Coding Update

On Tuesday, Jan. 8, from 11 a.m. to noon PST, the AAOE will host a Web conference that highlights the key coding changes for 2008. If you miss this Webinar, you can purchase it as a CD.

For more information, or to register, go to