Each year, Academy and AAOE members share thousands of coding-related comments at Codequest Coding Courses, via listservs, and by email.
In 2016, many practices have run into trouble during audits. You can learn from their costly mistakes.
Fear No Audit
The problem. Postpayment audits frequently find a discrepancy between what was documented and what was billed. As a result, practices have had to return large sums of money to payers.
The solution. To help you improve your documentation, the Academy has launched 3 online courses:
- Eye Visit Code Documentation Guidelines (Product #0120406V)
- Testing Services Documentation Requirements (#0120407V)
- Complete Guide to Documenting and Coding Cataract Surgery (#0120408V)
For more information, and to place your order, visit aao.org/store.
Delegating Tests to Staff
Some tests must be performed by physicians, others can be delegated. For Medicare Part B, tests that can be delegated have both a technical component (–TC) and a professional (–26) component.
Delegated tests have 3 levels of supervision1 under Medicare:
General supervision means that the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the physician has an ongoing responsibility for the training of the nonphysician personnel who actually perform the diagnostic procedure and for the maintenance of the necessary equipment and supplies.
Direct supervision in the office setting means that the physician must be present in the office suite and is immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
Personal supervision means a physician must be in attendance in the room during the performance of the service.
Avoid this mistake. Recent audits have demonstrated that the ordering or supervising physician wasn’t always on-site when tests with direct supervision were performed. As a result, Medicare has been able to recoup significant amounts of money.
Note: While Medicare Part B recognizes 3 levels of supervision, commercial plans recognize only direct supervision for all delegated testing services.
SCODI and Fundus Photos
The latest audit trigger involves CPT codes 92250 Fundus photography and 92134 Scanning computerized ophthalmic diagnostic imaging [SCODI], posterior segment, with interpretation and report, unilateral or bilateral; retina. SCODI is often performed the same day as an intravitreal injection, and physicians may order fundus photography on the same day, too. As codes 92250 and 92134 are bundled, practices may choose to submit the photography code for payment because it has a higher allowable.
The high use of the fundus photography code has triggered audits, with practices under scrutiny for:
- Use of modifier –25, which is used to unbundle codes
- Injection documentation
- Frequency of injected drug
- Supervision of testing
- Medical necessity of fundus photography
To learn your Medicare Administrative Contractor’s documentation requirements for testing services, look for the relevant local coverage determination at aao.org/practice-manage ment/coding/updates-resources/practice-management/coding/updates-resources.
A number of cataract surgeons have had to return payments for cataract surgery after audits revealed documentation problems, including the following:
- No evidence of the patient’s preoperative best-corrected visual acuity (BCVA) in the record.
- No evidence of the patient having reported impairment of visual function resulting in restriction of activities of daily living.
- No signed operative note/report.
- No documentation indicating that the patient desires surgical correction; that the patient has received an explanation of the risks, benefits, and alternatives; and that the expected outcome will significantly improve visual and functional status.
Further Reading. Read “Best Coding Tips of 2015: Part 1” (November 2015) and “Part 2” (December 2015), as well as “#1 Lesson From the Chart-Auditing Service: Get Your History Right” (June 2015).
1 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/B0128.pdf. Accessed Sept. 21, 2016.