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Young Ophthalmologists
Regulatory Updates for 2012
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With all of the rapidly occurring coding changes, there are a few that deserve particular attention. These include audits, the ICD-10 transition and updates to the Physician Quality Reporting System and e-prescribing incentive programs.

Audits – What Now
RAC Demand Letters
As most practices are already aware, the responsibility for the issuance of Recovery Auditor Contractor (RACs) demand letters was shifted as of Jan. 1 to Medicare administrative contractors (MACs), fiscal intermediaries and carriers. 

undefinedAt the present time, a separate demand letter is being generated for each individual transaction. CMS is working with the system maintainer to ensure transactions are aggregated at the provider level on a daily basis. Their goal was to have the aggregation process in place by mid-January. However, until the letters begin to aggregate by provider, a provider who experiences multiple RAC adjustments that result in multiple overpayments on a given day will receive a separate demand letter for each individual overpayment.

CERT Audit Outcomes
Comprehensive Error Rate Testing (CERT) is Medicare auditing Medicare by auditing you. The following is a list of errors CERT has identified.

  • Insufficient medical record documentation
  • Illegible or no physician signatures
  • Missing valid electronic or hand written physician signatures
  • Missing the physician orders, plan-of-care documentation and progress notes to support the medical necessity of services
  • Missing documentation of intent to perform diagnostic test
  • Missing documentation to support medication administration
  • Claims coded incorrectly

MACs have been informed that these areas need to see improvement. Remember, CERT shares their error findings with RACs.

Zone Program Integrity Contractors
The mission of these contractors (“ZPICs”) is to identify potential fraud by reviewing any claims, even those pending payment by investigations and audits. ZPICs compare billings with similarly situated providers and are authorized by CMS to:

  • Suspend payments;
  • Determine overpayments and
  • Refer providers for exclusion from government health care programs.

ZPICs also provide support to law enforcement. In addition:

  • Audits are never random. The physician is already under investigation for possible fraud.
  • The initial request for data is an indication as to the nature of the investigation.
  • Onsite inspections, announced or unannounced, include requests for additional documentation, interviewing of Medicare beneficiaries as well as physician employees.
  • Audits are initiated from: data analysis of high frequency of certain services, complaints by whistleblowers which can be reports to the Office of the Inspector General, hotlines, fraud alerts or direct to ZPIC, referral from MAC, RAC.

In one case, a five-physician practice underwent a 120-chart audit covering 18 months’ time span, based on whistleblower action that alerted a ZPIC. The practice received a demand letter one year later for repayment of $4 million. The contracted auditor said it found a 34 percent error rate. The practice appealed at all levels and in the final outcome, an administrative law judge’s decision resulted in a $1,300 recoupment.

2012 PQRS Update
For 2012, there are three options for PQRS reporting:

  • Option 1: Practice must exceed 50 percent correct reporting on at least three measures when reporting via claims.
  • Option 2: Registry. Practice must exceed 80 percent reporting on at least three measures.
  • Option 3: Cataract measure group. Report a minimum of 30 surgical patients through a qualified CMS registry.

Other changes:

  • There is only one reporting period, Jan. 1, through Dec. 31.
  • Incentive payments will be 0.5 percent of all your Medicare Part B, Medicare as a secondary payer and Railroad Medicare allowables, (except for durable medical equipment, injectable solutions and facility).
  • Glaucoma staging add-on (+) codes have been added to glaucoma measures 12 and 141.

Details for all specialties can be found at; email questions to

2012 E-Prescribing Update
To get 1 percent of all your Medicare Part B, Medicare as a secondary payer and Railroad Medicare allowables (except for durable medical equipment, injectable solutions and facility), offices must submit G8553 a minimum of 25 times during the reporting period, Jan. 1 to Dec. 31. Each G-code must be associated with an exam.

In order to avoid the 2013 penalty, physicians who do not qualify for an exception or exemption may report G8553 a minimum of 10 times, linked to any billable CMS service (such as an exam, test, or surgical code) between Jan. 1 and June 30, 2012. If not linked with a qualifying exam, the e-prescribing will not be counted as part of the required minimum of 25 for the incentive payment.

Details can be found at; email questions to

ICD-10 Transition
With approximately two years to go until we transition to ICD-10, physicians, administrators, office managers are asking, “What should I be doing now?” You can begin to familiarize yourself with ICD-10 by learning anatomy and physiology specifics you’ll need to know.

AAOE has produced the Ophthalmic Anatomy and Physiology for ICD-10 module. The module offers a maximum of 1.0 AMA PRA Category 1 Credits™ and JCAHPO “Group A” CE credits. 

  • All participants must complete an online post-test and the course evaluation form to receive the appropriate CME or CEU credit for this activity.
  • You must earn a score of 80 percent or greater to be eligible for CME and CEU credit.
  • The AAPC will accept a certificate reporting AMA PRA Category 1 Credits™. Visit for more information.

There will also be more information and resources on ICD-10 at the Joint Meeting in Chicago, Nov. 10 to 13. For more information about the ICD-10 transition, visit; email questions to

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About the author: This article has been adapted from the original, which appeared in the January 2012 issue of Coding Bulletin. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.

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