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The six examples presented are real. Each case presents the:
- Financial Impact
Scenario: Medicare requested 35 records from an ophthalmologist for claims coded as CPT code 99214 Level 4 E&M established patient.
Error: The ophthalmologist reported never having coded 99214, only 92014 Eye code established comprehensive exam, and the staff person was not trained in ophthalmology and had been switching the codes when submitting the claim.
Outcome: The ophthalmologist failed the audit and all charts were down-coded to 99213 Level 3 E&M established patient.
Financial Impact: First, the difference in Medicare’s allowable, i.e., 99214 $83 vs. 92014 $96 = loss of $13 per claim X 35 records = $455 loss in revenue had the codes not been switched. Second, the difference in Medicare’s allowable, i.e., 99213 $53 and 99214 $83 = $30 x 35 charts, necessitating a payback to Medicare in the amount of $1,050. In addition, the physician will be audited again within three to six months to assure compliance.
Cure: Had the ophthalmologist reviewed the procedure productivity reports, he/she would have noticed the wrong code was being submitted. Proper training of staff is vital.
Scenario: Every time the physician performed any laser procedure, it was coded as CPT code 66821 YAG laser capsulotomy.
Error: The surgeon never marked or approved the code the staff selected on the superbill. In addition, the staff did not know there are many types of laser procedures.
Outcome: The physician was audited on 10 charts for YAG capsulotomy. Only two of the 10 cases were actually YAG laser and met the criteria, five were ALT and three were LPI.
Financial Impact: 66821 YAG laser: $240 x 2 = $480. 65855 ALT: $302 x 5 = $1,510. 66761 LPI: $358 x 3 = $1,074. By submitting only the YAG laser code for these 10 charts, initial loss of revenue was $664. The loss was actually much, much more when the amount of surgeries performed beyond the audit is taken into consideration.
Cure: Had the ophthalmologist marked his/her own superbill and reviewed the procedure productivity report, he/she would have noticed the wrong codes were being submitted. Again, proper staff training is vital.
Scenario: A new coder without ophthalmology experience.
Error: Submitting claims for CPT code 66850 Removal of lens material; phacofragmentation technique instead of submitting CPT code 66984 Cataract extraction with IOL. In this case, the staff person became aware of the error during state-sponsored CODEquest Coding College.
Financial Impact: The difference in allowable between the two codes is $32. The error had been made for two years. Approximately 200 cataract cases in a year times two years times $32 = $6,400 in loss revenue.
Cure: If the surgeon has marked the superbill and carefully reviewed the procedure productivity report, the error would have been caught.
Scenario: The payer audited 15 records of CPT code 67840 Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure. In order to use this code, removal must include more than skin (i.e., involving lid margin, tarsus and/or palpebral conjunctiva). On each of the 15 charts, the surgeon has removed the multiple lesions on the upper and lower lids of the same eye. The typical claim submitted was: 67840-E1 = $276; 67840-59-51-E1 = $138 (50 percent reduction); 67840-51-E2 = $138 (50 percent reduction).
Error: CPT code 67840 is payable per eye, not per lid or lesion, resulting in an overpayment of $276 per claim x 15 ($4,140 total), but that’s not the worst of it. Chart documentation did not warrant that level of service; and all 15 charts were down-coded to CPT code 11440 Excision, other benign lesion, including margins, except skin tag, eyelids. CPT code 11440 is payable per session, not per lesion, lid or eye.
Outcome: The allowable for CPT code 11440 is $120 per session.
Financial Impact: For those 15 records, the ophthalmologist had been paid approximately $8,280. With the down-coding from the lack of documentation and the session versus eye coverage difference, the amount the physician would have been paid was $1,800. This resulted in the physician refunding $6,480 to the payer.
Cure: Prior to performing the procedure, discover if its payable per lesion, lid, eye or session and document exactly what is performed. In addition, know the LCD for benign/malignant skin lesion removal and be clear on master modifier application. Applying modifier 59 separate procedure allowed the payer to erroneously pay per lesion.
Scenario: The surgeon performed CPT code 66170 Fistulization of sclera for glaucoma, trabeculectomy ab externo in absence of previous surgery at the time of CPT code 66984 Cataract with IOL. The claim was submitted as: 66984-LT = $654; 66170-59-51-LT = $452 (50 percent reduction). Total payment was $1,106. In addition, modifier 59 was appended to unbundle the procedures, according to the version of CCI the office was using (7.0). At the time of surgery, CCI version 12.2 was in effect and the two procedures were not bundled.
Error: Inappropriate use of modifier 59. Also, the trabeculectomy has higher RVUs than that of cataract. Therefore, the order in which the codes were submitted was incorrect.
Financial Impact: 66170-LT = $904; 66984-51-LT = $327 (50 percent reduction) making a total payment of $1,231 and loss of $125 per case.
Cure: Always use the current version of CCI and list the codes in order of highest to lowest allowable. Recognize when to use modifier 59 and, equally important, when not to use it. Train the person processing EOMBs to look for these types of errors.
Scenario: Established surgeon with 20 years practice experience, routinely performs functional blepharoplasties.
Error: Ten blepharoplasty cases were audited. The surgeon had never read Medicare’s LCDs, which outline specific criteria for surgery. The audit revealed that two of the surgeries did not qualify as functional, but instead were cosmetic. The surgeon never obtained an ABN, which is recommended in all oculoplastic cases for just this reason. Without an ABN and associated modifier GA, the surgeon can’t bill the patient and instead performed the surgeries for free.
Financial Impact: 15823-RT = $506; 15823-51-LT = $253 (50 percent reduction). Total refund paid to Medicare: $759 x 2 = $1,518.
Cure: First, know the rules of the LCDs. They provide the documentation guidelines by which you are held accountable. Second, obtain an ABN and append the associated modifier GA on all oculoplastic claims. Had that been done, the patient would have been responsible for payment.
So, what does it take to code correctly?
- Physicians should mark or routinely evaluate how the superbill is filled out.
- Staff should not have the authority to make a code change without consulting the physician who is ultimately responsible.
- Have access to the current CCI.
- Have knowledge of LCDs (available on payer Web sites).
- Know when to obtain an ABN from the patient.
- Remember to append modifier GA to the claim when appropriate.
- Use proper modifier application. In 2003, an OIG investigation found that 40 percent of the CCI code pairs billed with modifier 59 did not meet the program requirements, resulting in $59 million in improper payments.
- Have a fee schedule or RVUs for all procedures billed.
- Have a monthly or quarterly review of procedure productivity reports by physician.
- Ensure the proper training of physicians as well as staff, including those who process the EOMBs.
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About the author: This article was originally presented by John Haley, MD, OCS; Steve Kamenetzky, MD, OCS; and Sue Vicchrilli, COT, OCS, coding executive, during the 2006 Joint Meeting in Las Vegas.